The Mouth Is Like a Black Hole Seek and ye shall find: Recognition of Oral Lesions in the Exam Room Lisa Fink, DVM, DAVDC Dentistry & Oral Surgery Service October 4, 2015 But he s friendly at home Part of a Complete Physical Examination Should be performed on all patients as temperaments permit Most patients will allow an awake extraoral/intraoral exam Ensure you have proper assistance Technician/assistant Towels/blankets Tongue depressors Image courtesy of www.paws-and-effect.com Let s start from the basics for a little review Always Wear Gloves!
Periodontal Pathogens PLAQUE IS A BIOFILM AND THE SULCUS/POCKET IS THE MOST FAVORABLE ENVIRONMENT Starts with Gram +, cocci, aerobic, non-motile bacteria As biofilm progresses, population changes to: Gram -, rod, anaerobic, motile bacteria Look At Me! J Vet Dent 14(3), 1997 Palpate the Muscles of Mastication Temporal and masseter Symmetry Pain Swelling Atrophy Neoplasia Foreign Body Palpate the ventral border of both mandibles Bony changes Symmetry Firmness Also the intermandibular space! Retropulse the Eyes This is extremely important Decreased retropulsion or pain can signify a retrobulbar mass or disease process Palpate under the Eyes Make sure there is no pain or swelling or fluid pockets
Palpate the lymph nodes and salivary glands Mandibular lymph nodes If enlarged, can perform FNA easily on awake patient Mandibular salivary glands Check Both Nostrils for Airflow Look In the Ears Check for evidence of otitis, stenosis, pain, or swelling Palpate the External Ear Canal Awake Oral Examination Overview Extraoral Muscles of mastication Staining (salivary or other) Wounds Any asymmetry Ocular retropulsion Nasal airflow Lymph nodes Salivary glands Ears Then comes the intraoral exam Teeth Number, size Fractures Attrition/Abrasion Color Occlusion Soft tissues
MUCOSA MUCOGINGIVAL JUNCTION (MGJ) ATTACHED GINGIVA FREE GINGIVA GINGIVAL MARGIN MUCOSA GINGIVA How many teeth does a dog with normal dentition have? 42 Copyright 2015 Bonnie R. Miller I 3/3 C 1/1 P 4/4 M 2/3 = 42 Canine Dental Formula How many teeth does a cat with full dentition have? 30
I 3/3 C 1/1 P 3/2 M 1/1 = 30 Feline Dental Formula Palpate the Juga of the Teeth Swellings Draining Tracts Bony changes Infraorbital Nerve bundle Juga vs. Jugum Intraoral Exam Continued Tongue Buccal mucosa Palate (Tonsils) only anesthetized patients Make a habit of checking these on all patients What s going on here? Complicated crown root fracture of tooth 208 Important questions to ask: When did the fracture occur? How old is the pet? How much of the tooth remains? 206, 207, 208, 209
Treatment options? Extraction Extraction Root canal therapy Vital pulp therapy Extraction Root Canal Therapy Access Instrumentation Sterilization Obturation Restoration Vital Pulp Therapy Access Removal of 7-10 mm inflamed pulp Pulp dressing Restoration Allows the tooth to stay ALIVE! Rules of Thumb If the animal is LESS THAN 18 months of age 2 weeks for Vital pulp If the animal is OLDER THAN 18 months of age 48 hours for Vital pulp
Why Does Age Matter? Time from pulp exposure to vital pulp therapy % Vital at 36 Months < 48 Hours 88.2% 2 7 Days 41.4% 1 3 Weeks 23.5% What about this tooth? All you need to know: Pulpitis Reversible Irreversible In our case usually due to concussive damage
Treatment Algorithm Discolored Tooth What is the arrow pointing to? YES Radiographic signs of pulpal necrosis? NO Root Canal Therapy Extraction Recheck X- Rays in 6 months Root Canal Therapy Extraction Lingual Molar Gland Small mixed salivary gland on the lingual aspect of the mandibular 1 st molar in cats Should not be removed but function does not appear to be decreased if it is removed Okuda et al. J Vet Dent, 13(2), 1996 Pyogenic Granuloma Pink to red, focal, lobulated, raised lesions Can mimic SCC in appearance Can be uni- or bilateral Histo: granulation tissue with variable edema and neutrophilic inflammation Treatment: Excision of soft tissue component Extraction of ipsilateral Max P4/M1 (+Mand M1)
Gingival Enlargement Inflammatory Drug induced Cyclosporine, calcium channel blockers, anticonvulsants Associated with systemic conditions Pregnancy, puberty Neoplastic False enlargement Exostoses, buccal bone expansion Treatment Discontinuation of the offending drug if possible Periodontal surgery Gingivectomy/gingivoplasty Biopsy Oral hygiene Oral home care 2x daily brushing Plaque control Chlorhexidine gel
Alveolar Bone Expansion Often in the region of canine teeth But not always! May be found in conjunction with periodontitis and/or tooth resorption Histopath: Benign woven bone Sclerotic bone Inflammatory remodeling of bone What s going on here? J Am Vet Med Assoc. 2015 Mar 15;246(6):654-60 Design Retrospective case series (14 years) Animals 95 cats with stomatitis Results 6.3% had no improvement 26.3% had little improvement 39.0% showed complete symptomatic relief 28.4% were clinically cured
Clinical Relevance 68.8% of these symptomatically or clinically cured cats required extended medical management for a finite period to achieve this positive outcome. Extent of tooth extraction (PME versus FME) was not associated with overall response to treatment. At initial recheck examination, patients displaying resolution of FS-related behavioral symptoms, decreased inflammation or lack of need for follow-up medical management with antibiotics were associated with a better long-term response to tooth extraction (OR 7.2, 3.5 and 3.7, respectively). Eosinophilic granuloma Lip/rodent ulcers Plaques on any surface of the oral cavity Secondary to allergic conditions Flea allergy dermatitis Insect bite hypersensitivity Atopy Treatment Flea treatment!! Historically: Prednisone 1-2 mg/kg/d on a slow taper More recently, Clavamox has also been proposed as a treatment due to secondary bacterial component Thank you! Questions? Dentistry@cuvs.org All lesions shown to have a bacterial component Plaques: 96.2% reduction in size 80% reduction in micro. fields with infection Lip ulcer: 65% reduction in micro. fields
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