Diagnosis: When tooth resorption (TR) is seen on routine dental radiographs, the next step is to carefully evaluate the tooth with a dental explorer along the gingival margin and look for clinical evidence of resorption (a sticky or rough area at or just below the gum line).
Treatment: If clinical evidence of resorption is found, the tooth should be extracted. If there is no clinical evidence of a lesion, radiographic monitoring is acceptable, as root resorption is reported to be non-painful in humans. Extractions of these teeth can be challenging due to the high degree of ankyloses and resorption, and referral to a veterinary dentist is strongly recommended. Crown amputation is not a recognized treatment for these lesions.
Diagnosis: This figure also represents TR.
Treatment: Extraction is normally recommended; however, crown amputation recently has been recommended as a treatment option for advanced type-2 TRs. This determination is possible through dental radiographs. Crown amputations must be performed only if the following radiographic conditions are met:
Diagnosis: This is a case of canine enamel hypocalcification, which occurs when the enamel-forming organ is damaged during enamel development, between 3 to 5 months of age (ie, prior to eruption). When the tooth erupts into the permanent dentition, malformed enamel flakes off, exposing the underlying dentin, resulting in several deleterious effects. The exposed dentinal tubules cause sensitivity (pain) for the patient, and oral bacteria may gain access into the endodontic system via these tubules, resulting in septic pulp necrosis. Finally, the roughened dentin surface results in increased plaque attachment and more severe periodontal disease. The tooth is also weaker and aesthetically unpleasing.
Treatment: These teeth should be treated with a composite restoration, which will resolve the sensitivity and block the pathway for infection. The restoration also will smooth the tooth and decrease periodontal disease, and should restore the tooth to at least near-normal appearance. Some strength will be restored, but if strength is a concern, a metal crown is recommended.
Diagnosis: This is a complicated crown fracture, because it has resulted in direct pulp exposure. The pulp is necrotic and septic, as evidenced by the dark exposed endodontic system.
Treatment: A root canal, which will save the tooth and be much less traumatic than an extraction, is the ideal form of therapy. For minor teeth, such as incisors and premolars, extraction is acceptable. Major teeth (canines and carnassials), however, should be saved if at all possible. This is especially true of mandibular canine teeth.
Diagnosis: This is an uncomplicated crown fracture. The dentin is exposed, but the endodontic system is not. The dentin exposure results in exposure of the dentinal tubules, which contain extensions of the root canal system. Therefore, this is considered an indirect exposure of the endodontic system. These teeth are painful and can result in endodontic infection and abscessation, and the roughened tooth surface may result in increased plaque and calculus accumulation, hastening the onset of periodontal disease. Definitive diagnosis requires careful evaluation of the exposed dentin for small areas of pulp exposure.
Treatment: If pulp exposure is present, the tooth requires root canal therapy or extraction (as in complicated crown fractures). If there is no pulp exposure, dental radiographs are needed to determine if the teeth are still alive. If there is evidence of endodontic infection, root canal therapy or extraction is required. If there is no evidence of infection, a bonded sealant is recommended to block off the pain and infection, as well as smooth the tooth. Since recent tooth death will not be recognized radiographically, rechecking with dental radiographs at 6–9 months is strongly recommended.
Diagnosis: The probe in this picture passes 3 mm (approximately halfway) but not completely through the furcation and is therefore considered a class II furcation. Class II and III (through and through) furcations cannot be cleaned without visualization afforded with a periodontal flap. Ultrasonic scaling and/or closed root planing results in infection remaining on the teeth and continued periodontal disease.
Treatment: When furcation level II or III teeth are found on oral examination, periodontal flap surgery and open root planing is required for cleaning. Extraction is another option. Furcation level II teeth have a good prognosis for bone regrowth with guided tissue regeneration, a less invasive but much more technically involved procedure than surgical extraction. Furcation III teeth can be cleaned, but prognosis for regeneration is poor; therefore, patients with major teeth (particularly the mandibular first molars) with furcation level II should be referred for periodontal flap surgery and guided tissue regeneration. Minor teeth (especially those with class III furcation) are best treated with extraction.
Diagnosis: This is a 4-mm periodontal pocket. While there are exceptions to every rule, normal sulcal depth for a dog is 0–3 mm; therefore, attachment loss is present in this area.
Treatment: Pockets of this depth can generally be treated with closed root planing and, ideally, instillation of a sustained-release antibiotic. The tooth should be further assessed for mobility and furcation exposure and treated as indicated. In addition, dental radiographs must be obtained and interpreted as part of the assessment, treatment planning, and documentation.
Pockets greater than 6-mm cannot be effectively cleaned without direct root visualization. Therefore, the options are either periodontal flap surgery to afford direct root visualization and complete cleaning, or extraction. These defects can be repaired via guided tissue regeneration, provided that an oronasal fistula has not developed. This procedure involves creating a palatal flap and thoroughly cleaning the pocket and root surface. Following the cleaning, bone augmentation and a barrier membrane is placed and the flap sutured closed. This procedure is much less invasive but somewhat more technique-sensitive than extraction and should be considered only if the client is committed to providing effective daily home plaque control and returning for (at least) annual evaluations and maintenance therapy. Consider a referral for this procedure, but it can be learned by general practitioners.
Diagnosis: There are 4 possibilities for a missing tooth:
The dental radiograph revealed a retained tooth root with periapical as well as periradicular rarefaction, indicating infection. Taking a radiograph is the only way to differentiate.
Treatment: The proper therapy is surgical extraction.
Another radiograph reveals an impacted first premolar tooth and a very large area of bone destruction, which is most likely a dentigerous cyst.
Treatment: This patient should be referred to a veterinary dentist for removal of the cyst and all the teeth that have lost their bone support, because this can be a challenging situation to manage.
Diagnosis: This is a persistent deciduous canine tooth. Studies have shown that periodontal and orthodontic ramifications begin as early as days to weeks (respectively) of the permanent tooth erupting.
Treatment: Immediate extraction of the tooth is recommended. However, a dental radiograph should be exposed to determine the condition of the deciduous root prior to extraction.
Diagnosis: This patient has feline juvenile periodontitis—not caudal stomatitis, as there is no evidence of caudal mucositis. Feline juvenile periodontitis is an infections etiology, as opposed to inflammatory, as seen with caudal stomatitis.
Treatment: This includes a complete oral hygiene procedure with full-mouth radiographs and extraction of the significantly infected teeth. The client must be instructed that stringent homecare will be required. With proper care, approximately 50% of these cases will resolve at 2 years of age; the other 50% will have chronic inflammation. Full-mouth extractions are not necessarily indicated at this time, but may be beneficial in refractory cases.
©Brook Niemiec, DVM, DAVDC, DEVDC, FAVD, Southern California Veterinary Dental Specialties & Oral Surgery, San Diego & Murrieta, California, & Las Vegas, Nevada