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When should patients with dental problems be referred?
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Veterinary dentistry was at a standstill for many years. So it is hard for many practitioners to understand the importance of advanced oral medicine, oral surgery and dentistry. Donald H. DeForge tried to create a catalogue of dental problems which should be refered to the specialists.
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Veterinary dentistry has been associated with only teeth cleaning for too long. It is true that the periodontal prophylaxis and homecare oral hygiene program are at the center of the hub of preventive veterinary dentistry. It is also important to realize that from that hub are a multitude of oral medicine and oral surgery spokes that allow the wheel to function.
Through this understanding, the veterinary dentist becomes a true partner in oral health maintenance with the general practitioner and his or her clients. In this column, I will identify three cases in which consultation with a veterinary dentist or specialist in oral care is advised.
Pulp exposures
Pulp exposures should be clinically identified only with the patient under inhalant anesthesia (i.e. isoflurane and sevoflurane). I still hear horror stories from clients where practitioners are pushing explorers into suspect open pulp canals, to see if there is pain, with the patient awake in an exam room setting. If you do not believe this hurts, ask your dentist to push an explorer into an open pulp canal in your mouth or a carious defect with deep dentinal or pulpal pathology.
There is no need to cause pain. Perform pre-anesthetic testing, decide upon the correct anesthetic protocol and with an inhalant anesthetic monitor the patient well while your diagnostics is proceeding. Place an explorer into the opening of the pulp canal and see if the explorer drops into pulp tissue. Bleeding may occur at this point. If the explorer does not drop but sticks in the dentin, this is also a sign of potential pulp disease. The next step is radiology of the tooth. No practitioner should proceed to this point without dental X-ray in his or her facility. It makes no sense to anesthetize the animal without having dental radiography on site. The dental X-ray is essential to a diagnosis and potential referral.
Exposure of the pulp left untreated leads to pulpal necrosis from bacterial infection. After pulp exposure, when the main concentration is placed on maintaining pulp vitality, the veterinary dentist must decide on the benefit of pulp capping or the vital pulpectomy. Root canal therapy is another option based on many factors including time of pulp exposure, age of the patient and radiographic findings.
Even though uncommon, root fractures in oral trauma patients must also be identified. These are not always easy to see and necessitate multiple X-ray projections and magnification to diagnose. The veterinary dentist will not only determine their presence, but also initiate a treatment plan to allow the tooth to be saved. These procedures need immediate attention and careful follow-up to be effective. A detailed discussion of root fracture treatment options go well beyond the scope of this essay and the reader is advised to seek further knowledge through continuing post-graduate courses or by consulting textbooks in veterinary and human dentistry.
Advanced stage periodontitis
In this case, the patient is presented in an advanced stage of periodontitis. The calculus and plaque have already been removed under isoflurane anesthesia with a piezoelectric ultrasonic root-planing unit (Satelec-Suprasson/R-P5 Booster). Upon clinical examination and probing, the following were identified:
Bleeding on probing
Ulceration at the free gingival margins in multiple sites in the anterior maxilla.
Gingival recession
Infrabony pockets that measured greater than 5 mm palatal to and mesial to #104 and #204, the maxillary cuspids (canine teeth).
Severe attrition of all dentition
The veterinarian can make the crowns look perfect and the teeth `shine,` but the benefit of the treatment of the patient is zero! This case is a prime example of my discussion of the new human classification schemes of periodontal disease (Ann Periodontol. 1999; 4: 1-6). Is this chronic periodontitis with slow to moderate disease progression with periods of rapid attachment loss?
On the other hand, is the patient affected by aggressive periodontitis or a necrotizing periodontal disease? Is there a gingival or periodontal abscess?
A gingival abscess is a local site affecting the free gingival margin or interdental papilla. A periodontal abscess is again local but is deeper in origin in a periodontal pocket causing damage to the alveolar bone and periodontal ligament. Finally, with the attrition present is there also periodontitis present associated with endodontic lesions? Periodontitis can start coronally and spread apically until it reaches pulp tissue through the root apex. Primary endodontic disease can also be present in this patient by invasion of bacteria into open pulp canals.
All of these categories are important to understand and differentiate. Each has its own special treatment plan. With each, a homecare oral hygiene program is essential. Most importantly, follow-up care is needed with dental radiology to monitor treatment progress and make any changes necessary for treatment success.
Oral growth, mass
The patient with the abnormal oral growth or mass should be referred. Diagnosis is based on clinical impression, radiology, incisional or excisional biopsy, and in some cases, C-scan imaging.
Superficial biopsies can lead to erroneous reports. Pathologists state over and over that correct histology is based on deep inclusive tissue specimen presentation. Many sites are difficult to approach. In many other instances, valuable time is lost because of an incorrect initial biopsy. For the patient depicted in this type of case, an initial biopsy, by the general practitioner, described only inflammatory tissue without neoplastic cells. In the second biopsy shown, an incisional biopsy with partial maxillectomy was performed at my center. The pathologist identified a fibrosarcoma in the maxilla.
The first biopsy performed by the general practitioner did not reach the site of the tumor. In my center, radiology prior to biopsy identified dystrophic calcification within a soft tissue mass, severe lysis of the maxilla, tooth disruption and nasal turbinate destruction. Because the practitioner did not have dental X-ray, these were not visible. His general X-ray unit showed overlapping dentition and non-parallel sinus irregularity. The red flag should have been raised and the referral made at this early juncture.
Source: Donald H. DeForge (2002): Know when to refer your dental cases. In: DVM Newsmagazine January 1, 2002.
www.dvmnewsmagazine.com/dvm/
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