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Veterinarian Technician February 2012 (Vol 33, No 2)

Dental Checkup: Common Dental Pathology: It Must Be Recognized to Be Treated!

by Patricia M. Dominguez, BS, LVT, VTS (Dentistry)

    CETEST This course is approved for 1.0 CE credits

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    Ms. Dominguez performs dental radiography on a cat. (February 2012 Veterinary Technician cover photo by Glenn Davenport)

    An initial oral examination without sedation includes inspecting the oral cavity as well as the eyes, muzzle, nasal passages, and lymph nodes. If the patient is very painful or aggressive, sedation may be needed for even a cursory examination. Looking closely at a patient’s face can reveal ocular discharge or suborbital swelling. The size and symmetry of the submandibular lymph nodes should be noted to detect abnormalities. If possible, a patient’s mouth should be opened to view the tongue and palate. Lesions, ulcers, defects, discolorations, and masses should be noted. Examining the teeth and gingiva is essential to evaluate occlusion. Malocclusions can cause tooth-to-tooth and tooth-to–soft tissue trauma. Every oral examination should include a detailed history of the patient’s oral behavior, including answers to the following questions:

    • What type of food does your pet eat?

    • What does your pet chew on?

    • Does your pet prefer wet or dry food?

    • Have you noticed any changes in your pet’s chewing behavior?

    • Does your pet swallow food whole, chew with one side of the mouth, or drop food on the floor?

    • Does your pet go to its food dish but then become hesitant to eat?

    • Have you ever noticed excessive drooling, teeth chattering, or oral sensitivity in your pet?

    Collecting this information at the preanesthetic visit can help properly treat the patient on the day of the dental procedure.

    An initial oral examination can uncover common dental pathology in most affected patients. The examination should begin with the client present to allow discussion of findings and formulation of a treatment plan and to provide the opportunity to answer client questions. Most clients are interested in learning about the techniques and treatments that are available in veterinary dentistry. I find it very useful to have a photo album of common dental pathology as well as skull models in the examination room. I use the photo album to show clients dental images and radiographs from a comparable case. The skull models allow me to show why the abnormality is important to treat in relation to other anatomic structures.

    The following common dental pathologies require evaluation and, often, treatment:

    • Missing teeth

    • Crowded teeth

    • Persistent primary teeth

    • Rotated teeth

    • Supernumerary teeth

    • Mobile teeth

    • Fractured teeth

    • Discolored teeth

    • Furcation exposure

    • Attrition

    • Abrasion

    • Oral masses

    For proper recordkeeping, abnormalities must be noted on the patient’s dental chart. Even removal of a primary tooth requires notation on a dental chart because the patient’s oral cavity has been evaluated and altered. The chart not only shows what was done in the oral cavity but also provides a future reference if the patient returns for other dental procedures. This allows evaluation of changes in the oral cavity and adjustment of treatment plans for teeth that are being monitored.

    Missing Teeth

    Missing teeth are characterized by a space in the dentition where a crown is not visible above the gingiva (FIGURE 1) . Simply noting a “missing” tooth on the dental record is not sufficient: a dental radiograph must be obtained to determine whether the tooth is missing or is impacted (blocked from erupting because of bone or another tooth), embedded (failing to erupt without obstruction), or fractured below the gumline. Because dentigerous (follicular) cysts can form around unerupted teeth, these teeth are often preemptively removed. Dentigerous cysts develop because the tooth follicle, which creates enamel, is not worn away as it would be during normal tooth development. It is important to properly diagnose these cystic areas, which are often confused with abscesses or neoplasms. Dentigerous cysts often become osteolytic and involve surrounding teeth before clinical signs appear. Therefore, the unerupted tooth should be removed after it has been detected by radiography. Retained tooth roots (FIGURES 2 and 3) (FIGURE 4) should also be removed to prevent further discomfort and infection.

    Crowded Teeth

    Teeth typically become crowded when more than one tooth tries to occupy the same location (FIGURE 5) , such as with persistent primary teeth (FIGURE 6) . If left uncorrected, crowded teeth can create a place where food, hair, and debris accumulate at a greater-than-normal rate, putting the patient at risk for a faster onset of periodontal disease. Persistent primary teeth can also cause developing adult teeth to erupt in an abnormal position, affecting occlusion.

    Rotated Teeth

    Rotated teeth are seen when teeth erupt at an irregular angle (FIGURE 7) . This is common in the upper premolars of small-breed or brachycephalic dogs. Probing for periodontal pockets and obtaining dental radiographs are necessary to evaluate whether these teeth should be extracted. If no abnormal pathology is noted, the client must be taught how to keep these areas clean using oral care products. The patient should return for professional evaluation every 6 to 12 months. Interceptive extraction of these teeth should be discussed with the client if adequate home care or regular professional cleanings are not options. Interceptive extraction is the removal of teeth that are prone to advanced periodontal disease due to their irregular location. This decreases the patient’s risk of future dental disease.

    Supernumerary Teeth

    Supernumerary teeth are extra teeth in the oral cavity (FIGURE 8) . Dental radiographs must be obtained to assess whether these teeth are harming other teeth or oral structures. Extra teeth may develop an abnormal root or may have a root that is displacing a neighboring tooth root. Because this can lead to periodontal disease, extra teeth should be removed. If an extra tooth is showing normal root development on radiographs and is not compromising other oral structures, the tooth can remain in place.

    Mobile Teeth

    Mobile teeth are teeth that have become compromised because of loss of bony attachment (FIGURE 9) , which can be due to periodontal disease, trauma, or a fracture. Early stages of periodontal disease with tooth mobility can be treated with periodontics and a strict home-care regimen. If periodontal disease progresses, the tooth’s mobility will increase and extraction will be necessary. The American Veterinary Dental College classifies tooth mobility as follows1:

    Stage 0: <0.2 mm

    Stage 1: >0.2 to 0.5 mm in a direction other than axial

    Stage 2: >0.5 to 1.0 mm in a direction other than axial

    Stage 3: >1.0 mm in any direction, including axial

    Fractured Teeth

    Tooth fractures are categorized as complicated or uncomplicated (FIGURE 10) . Complicated tooth fractures involve direct access to the pulp canal from the oral cavity, requiring immediate treatment (i.e., extraction or endodontic therapy). Uncomplicated tooth fractures involve only the enamel and dentin. Although uncomplicated fractures do not directly open into the pulp, treatment is required to seal the dentinal tubules to help prevent bacteria from traveling through them. Both types of fractures can involve the crown and/or root. The “watch and wait” approach should never be taken for fractured teeth because it only results in pain and the spread of infection.

    Discolored Teeth

    Discolored teeth generally change from pink to purple to gray (FIGURE 11) . This is usually due to trauma to the inside of an unbroken tooth. The inner portion of the tooth develops pulpitis (inflammation of the pulp), resulting in bruising that can be seen on the surface of the tooth. A study by Dr. Fraser Hale2 showed that 94% of discolored teeth have partial or total pulp necrosis, but only 58% of these teeth showed radiographic signs of necrosis. According to this study, the proper course of treatment is extraction or root canal therapy. Some clinicians think that if a discolored tooth is fully developed with a mature root canal and no radiographic changes are seen, the tooth can be monitored using yearly radiography; in addition, the client should be advised to watch for signs of oral sensitivity.3

    Furcation Exposure

    Furcation exposure occurs when periodontal disease degrades bone between root structures (FIGURE 12) . Oral examination with a periodontal explorer can reveal open access to the space where root structures meet to form the crown. Classification of furcation exposure is based on the extent to which the periodontal probe can be inserted into the furcation:

    Class 1—the periodontal probe can enter the furcation of a multirooted tooth but cannot pass more than halfway through on either side

    Class 2—the periodontal probe can pass more than halfway through the furcation but cannot exit the other side

    Class 3—the periodontal probe can pass through one side of the furcation and out the other; without proper oral care, these teeth usually must be extracted

    Attrition and Abrasion

    Attrition (FIGURE 13)  and abrasion  (FIGURE 14) describe wear on a tooth’s surface. Attrition or abrasion can result in damage to the enamel, dentin, and pulp. The difference between attrition and abrasion pertains to the object that causes wear on the tooth. Attrition is caused by tooth-on-tooth contact over time. Abrasion is due to wear by anything other than a tooth. Abrasion is most common in patients that chew objects such as tennis balls, rocks, or their cages. Dermatologic conditions can cause pets to chew and bite themselves, which can also wear teeth. When attrition or abrasion is seen, a dental radiograph must be obtained to properly evaluate the extent of tooth wear. This can determine whether repairing the tooth is possible using restorative, endodontic, and/or prosthodontic procedures. If wear due to abrasion is minimal, the client must commit to changing the patient’s chewing behavior to prevent the need for repair.

    Oral Masses

    A thorough oral examination may reveal abnormalities of the jaw structure; on/under the tongue; or on the gingiva, the hard or soft palate, or the back of the throat. Detailed charting of an oral mass should include its location, color, shape, size, and texture.

    Because it is impossible to determine by observation alone whether oral masses  (FIGURE 15) are benign or malignant, they should always be biopsied. Even obtaining a dental radiograph to examine bony involvement is not 100% accurate. In dogs, benign growths are usually gingival hyperplasia (overgrowth) or epulides (tumors of mixed cell origin). In cats, benign growths can be due to periodontal inflammation or an eosinophilic granuloma. Epulides tend to be more common in dogs than in cats.4 Epulides develop from periodontal ligaments and do not tend to spread or involve bone. Epulides are categorized as fibromatous, ossifying, or acanthomatous. If epulides—including the involved teeth and the originating periodontal ligament—are completely excised, they are unlikely to recur. Fibromatous and ossifying epulides are generally removed by surgical excision and have a low recurrence rate because they lack bony involvement. Acanthomatous epulides often require surgical resection or radiation therapy because of bony involvement.

    An aggressive, well-incised biopsy of the tissue for histopathology often allows definitive diagnosis, from which a treatment plan and prognosis can be made and communicated to the client. Obtaining digital images and radiographs during a biopsy can provide additional information to a pathologist and an oral surgeon. Dental radiography is necessary to visualize the extent of the tumor’s bony involvement. Further imaging using magnetic resonance imaging or computed tomography may be necessary if the tumor appears to involve the sinus cavity or ocular space.

    Clients should be encouraged to alert veterinary staff if a pet develops excessive drooling, bloody saliva, facial swelling, a change in appetite or chewing behavior, a foul oral odor, or a change in the oral cavity. Early recognition of oral masses  (TABLE 1) can allow for more effective treatment options, which commonly include chemotherapy, radiation, and/or surgical excision. Before treatment, it is usually recommended to obtain thoracic radiographs to rule out metastasis to the lung fields.

    Wide surgical excision is the best method for preventing the spread of cancer cells; this may require a hemi- or full mandibulectomy or maxillectomy followed by radiation. If the procedure is performed by a qualified surgeon, the cosmetic results can be barely noticeable. In some cases, the results can be drastic, but proper client education, including pictures of similar cases after healing, can ease a client’s concerns.

    The prognosis usually depends on the stage, size, and location of the tumor. Early detection of oral malignancies can improve the prognosis, but the prognosis can be poor even with early detection of some aggressive malignancies.

    By working with an oral surgeon and an oncologist, veterinary staff can help clients make the best decision for themselves and their pets. In cases in which treatment is not an option, care must be taken to ensure that the patient is not experiencing discomfort. Oral tumors can cause excessive salivation, oral bleeding, or inappetence. When these effects cannot be resolved, clients should consider euthanasia as the most humane option.

    Suggested Reading

    Bellows J. Feline Dentistry: Oral Assessment, Treatment, and Preventative Care. Hoboken, NJ: Wiley-Blackwell; 2010.

    Gorrel C. Saunders Solutions in Veterinary Practice: Small Animal Dentistry. London, UK: Elsevier; 2008.

    Gorrel C, Derbyshire S. Veterinary Dentistry for the Nurse and Technician. Oxford, UK: Butterworth-Heinemann; 2005.

    Norsworthy GD, Fooshee GS, Crystal MA, Tilley LP, eds. The Feline Patient. Hoboken, NJ: Wiley-Blackwell; 2010.

    Tutt C. Small Animal Dentistry: A Manual of Techniques. Hoboken, NJ: Wiley-Blackwell; 2007.

    Downloadable PDF

    Ms. Dominguez discloses that she has received financial benefits from American Veterinary Supply Corporation, Webster Veterinary, Pfizer, and Greenies.

    1. Recommendations adopted by the AVDC board. American Veterinary Dental College. http://www.avdc.org/nomenclature.html. Updated November 2010. Accessed November 2011.

    2. Hale FA. Localized intrinsic staining of teeth due to pulpitis and pulp necrosis in dogs. J Vet Dent 2001;18(1):14-20.

    3. Carmichael DT. How should I approach a discolored tooth? Vet Med October 1, 2010. http://veterinarymedicine.dvm360.com/vetmed/Dentistry/How-should-I-approach-a-discolored-tooth/ArticleStandard/Article/detail/690080. Accessed November 2011.

    4. Withrow SJ, Vail DM. Withrow and MacEwen’s Small Animal Clinical Oncology. 4th ed. St. Louis, MO: Saunders Elsevier; 2006.

    References »

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