Ekstraksi Dan Scaling Gigi Anjing [PDF]

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TUGAS MATA KULIAH ILMU BEDAH KHUSUS



TEKNIK OPERASI EKSTRAKSI DAN SCALING GIGI



KELAS: A



Milda Lailia



1409005076



Ruth Dwi Hartati



1509005030



Ni Kadek Dewi Suprabha



1509005031



Aditana Fanayoni



1509005033



Ni Kadek Meita Swandewi



1509005034



LABORATORIUM BEDAH VETERINER FAKULTAS KEDOKTERAN HEWAN UNIVERSITAS UDAYANA DENPASAR TAHUN 2018



RINGKASAN



Penyakit periodontal sangat sering dihadapi oleh dokter hewan praktisi, hal tersebut membuat klien menanyakan penyakit periodontal pada hewan kesayangan mereka. Faktor yang menyebabkan timbulnya penyakit periodontal adalah kebiasaan menggigit, grooming, status kesehatan, perawatan di rumah, bakteri yang aktif di ruang mulut, serta jenis pakan yang diberikan. Penyakit periodontal dapat menyebabkan kualitas hidup hewan berkurang. Penyakit periodontal juga dapat menyebabkan hewan mengalami kesulitan makan, bau mulut, dan kesulitan membersihkan dirinya (grooming). Penyakit periodontal dapat menyebabkan penyakit sistemik seperti komplikasi kardiovaskular, rheumatoid arthritis, gangguan kehamilan dan artherosclerosis. Penanganan penyakit periodontal yang utama adalah mengurangi mikroba patogen. Tindakan yang dilakukan untuk mengurangi mikroba antara lain scaling, root planning. Penanganan pada penyakit gigi hewan yang umum dilakukan adalah ekstraksi dan scaling gigi. Ekstraksi gigi merupakan pencabutan gigi dari soketnya pada tulang alveolar dan scaling gigi adalah proses pembersihan karang gigi. Kata kunci : ekstraksi, gigi, periodontal, scaling.



SUMMARY



Periodontal disease is very often encountered by veterinarian practitioners, it makes clients ask periodontal diseases in their pets. Factors that cause periodontal disease are habit of biting, grooming, health status, home care, active bacteria in the mouth space, as well as the type of feed given. Periodontal disease can lead to reduced quality of animal life. Periodontal disease can also cause animals to have difficulty eating, bad breath, and difficulty cleaning themselves (grooming). Periodontal disease can lead to systemic diseases such as cardiovascular complications, rheumatoid arthritis, pregnancy disorders and artherosclerosis. Handling of major periodontal diseases is to reduce pathogenic microbes. Actions taken to reduce microbes include scaling, root planning. Handling of common animal dental diseases is extraction and scaling of teeth. Tooth extraction is the tooth extraction from its socket on the alveolar bone and the dental scaling is the process of cleaning the tartar. Key words: extraction, tooth, periodontal, scaling.



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KATA PENGANTAR



Puji syukur penulis panjatkan kepada Tuhan Yang Maha Esa karena atas berkat rahmat-Nya penulis dapat menyelesaikan tugas paper Ilmu Bedah Khusus Veteriner yang berjudul “Teknik Operasi Ekstraksi dan Scaling Gigi”. Segala kritik dan saran sangat penulis harapkan demi kebaikan dari tugas ini. Terimakasih kepada dosen pengampu yang memberikan materi pada saat perkuliahan dan praktikum, teman kelompok yang sudah banyak membantu dalam proses pengerjaan paper ini. Dan tak lupa penulis mengucapkan banyak terima kasih kepada semua pihak yang telah membantu penulis.



Denpasar, 2 Oktober 2018



Penulis



iii



DAFTAR ISI HALAMAN JUDUL ................................................................................................. i RINGKASAN .......................................................................................................... ii KATA PENGANTAR ............................................................................................. iii DAFTAR ISI ........................................................................................................... iv DAFTAR GAMBAR ............................................................................................... v DAFTAR LAMPIRAN ........................................................................................... vi BAB I PENDAHULUAN......................................................................................... 1 1.1



Latar Belakang ..................................................................................... 1



1.2



Rumusan Masalah ................................................................................ 2



BAB II TUJUAN DAN MANFAAT TULISAN ....................................................... 3 2.1



Tujuan Tulisan .................................................................................... 3



2.2



Manfaat Tulisan .................................................................................. 3



BAB III TINJAUAN PUSTAKA ............................................................................. 4 3.1



Anatomi Gigi .................................................................................... 4



3.2



Penyakit Pada Gigi ............................................................................ 6



3.3



Ekstraksi Gigi.................................................................................... 6



3.4



Scaling Gigi ...................................................................................... 7



BAB IV PEMBAHASAN ........................................................................................ 8 4.1



Managemet Pre-Operasi ....................................................................... 8



4.2



Tindakan Anestesi................................................................................ 9



4.3



Teknik Operasi .................................................................................... 9 4.3.1 Ekstraksi Gigi ........................................................................ 9 4.3.2



4.4



Scaling Gigi ......................................................................... 12



Management Pasca Operasi................................................................ 15



BAB V SIMPULAN DAN SARAN ....................................................................... 16 5.1



Simpulan ........................................................................................... 16



5.2



Saran ................................................................................................. 16



DAFTAR PUSTAKA ............................................................................................. 17 LAMPIRAN



........................................................................................................... 18



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DAFTAR GAMBAR



Gambar 1 ................................................................................................................................ 4 Gambar 2 ................................................................................................................................ 5 Gambar 3 ................................................................................................................................ 5 Gambar 4 ................................................................................................................................ 10 Gambar 5 ................................................................................................................................ 10 Gambar 6 ................................................................................................................................ 10 Gambar 7 ................................................................................................................................ 11 Gambar 8 ................................................................................................................................ 11 Gambar 9 ................................................................................................................................ 12 Gambar 10 .............................................................................................................................. 12 Gambar 11 .............................................................................................................................. 13 Gambar 12 .............................................................................................................................. 13 Gambar 13 .............................................................................................................................. 14 Gambar 14 .............................................................................................................................. 14 Gambar 15 .............................................................................................................................. 15



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DAFTAR LAMPIRAN



Prevelence of dental disorders in pet dogs Applied Feline Oral Anatomy And Tooth Extraction Techniques



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BAB I PENDAHULUAN 1.1 Latar Belakang Indonesia sebagai negara berkembang membuat pola hidup masyarakat mengikuti gaya di negara maju. Salah satu gaya hidup yang diikuti adalah memiliki hewan kesayangan. Kucing dan anjing merupakan hewan peliharaan yang umum dimiliki oleh masyarakat. yang banyak digemari oleh banyak orang. Manfaat memelihara anjing dan kucing dapat terasa secara fisik dan mental. Anjing dan kucing merupakan hewan yang dekat dengan manusia sehingga perawatan harus selalu diperhatikan, Perawatan yang kurang baik dapat menyebabkan penyakit. Salah satu penyakit yang sering diderita anjing adalah penyakit periodontal. Penyakit periodontal sangat sering dihadapi oleh dokter hewan praktisi, hal tersebut membuat klien menanyakan penyakit periodontal pada hewan kesayangan mereka. Faktor yang menyebabkan timbulnya penyakit periodontal adalah kebiasaan menggigit, grooming, status kesehatan, perawatan di rumah, bakteri yang aktif di ruang mulut, serta jenis pakan yang diberikan (Gawor et al. 2006). Penyakit periodontal dapat menyebabkan kualitas hidup hewan berkurang. Penyakit periodontal juga dapat menyebabkan hewan mengalami kesulitan makan, bau mulut, dan kesulitan membersihkan dirinya (grooming). Penyakit periodontal dapat menyebabkan penyakit sistemik seperti komplikasi kardiovaskular, rheumatoid arthritis, gangguan kehamilan dan artherosclerosis (Kortegaard et al. 2014). Penanganan penyakit periodontal yang utama adalah mengurangi mikroba patogen. Tindakan yang dilakukan untuk mengurangi mikroba antara lain scaling, root planning (Fernandes et al. 2010). Penanganan pada penyakit gigi hewan yang umum dilakukan adalah ekstraksi dan scaling gigi. Ekstraksi gigi merupakan pencabutan gigi dari soketnya pada tulang alveolar dan scaling gigi adalah proses pembersihan karang gigi.



1



1.2 Rumusan Masalah 1.1.1. Apa yang dimaksud dengan ekstraksi dan scaling gigi ? 1.1.2. Bagaimana manajemen pre operasi ekstraksi dan scaling gigi ? 1.1.3. Bagaimana teknik operasi ekstraksi dan scling gigi ? 1.1.4. Bagaimana manajemen pasca operasi ekstraksi dan scaling gigi ?



2



BAB II TUJUAN DAN MANFAAT TULISAN



2.1 Tujuan Tulisan 1. Untuk memahami apa yang dimaksud dengan ekstraksi dan scaling gigi 2. Untuk mengetahui manajemen pre operasi ekstraksi dan scaling gigi 3. Untuk memahami teknik operasi ekstraksi dan scaling gigi 4. Untuk mengetahui manajemen pasca operasi ekstraksi dan scaling gigi 2.2 Manfaat Tulisan Penulis berharap melalui paper yang kami yang buat berjudul “Teknik Operasi Ekstraksi dan Scaling Gigi” dapat memberikan informasi dan pengetahuan kepada pembaca, sehingga pembaca dapat mengetahui definisi dan bagaimana prosedur dan teknik ekstraksi dan scaling gigi, yang baik dan benar sehingga dapat menerapkannya dalam prakteknya.



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BAB III TINJAUAN PUSTAKA 3.1 Anatomi Gigi Struktur primer dari ruang mulut terdiri atas gigi, gusi, lidah, palatum durum, dan palatum nuchae. Setiap spesies memiliki formula gigi yang berbeda. Formula gigi adalah jumlah dan tipe dari gigi pada mulut yang normal. Mamalia umumnya memiliki dua jenis gigi yaitu, gigi primer atau deciduous dan gigi permanen. Kucing memiliki empat tipe gigi yang terdiri dari gigi incisivus, caninus, premolar dan molar (Perrone, 2013). Deciduous anjing sebanyak 28 buah (12 incisor, 4 caninus, 8 premolar dan 4 molar), sedangkan gigi permanen sebanyak 42 buah (12 incisor, 4 caninus, 16 premolar dan 10 molar) (Pieri e al. 2012).



Gambar 1 Diagram Gigi Kucing (Crossley 2002). Gigi 101 – 109 adalah gigi pada maxilla kanan, gigi 201 – 209 adalah gigi pada maxilla kiri. Gigi 301 -309 adalah gigi pada mandibular kiri dan gigi 401 – 409 adalah gigi pada mandibular kanan



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Gambar 2. Diagram Gigi Anjing (Crossley 2002) Struktur anatomi gigi terdiri atas crown, enamel, cementum, dentin, pulpa, dan akar. Crown adalah bagian gigi yang terletak di atas gusi dan akar gigi adalah bagian gigi yang berada di bawah gusi. Enamel adalah bagian yang melindungi crown dan cementum adalah bagian yang melindungi akar gigi. Pulpa terdiri atas jaringan ikat, nervus, dan pembuluh darah (Perrone, 2013).



Gambar 3. Struktur anatomi gigi



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3.2 Penyakit Pada Gigi Penyakit gigi yang umum terjadi pada hewan peliharaan adalah: 



Dental calculus (tartar). Tartar berkembang membentuk calculus atau karang gigi, menumpuk di antara gigi dan gusi dan merangsang perkembangan







bakteri di daerah tersebut. 



Radang gusi, tumpukan tartar dapat mengiritasi gusi dan menyebabkan peradangan pada gusi. Radang gusi terlihat dari gusi yang berwarna merah







tua di daerah perbatasan dengan gigi. 



Penyakit periodontal. Periodontal berasal dari dua kata yunani yaitu Peri yang berarti pinggiran atau sekitar, dan dontal yang berarti gigi. Penyakit periodontal adalah gangguan pada gigi dan daerah sekitarnya yang biasanya disertai peradangan. Penyakit ini dapat mengganggu jaringan penahan yang







terdapat disekitar gigi, akibatnya gigi menjadi goyah dan mudah lepas. 



Fraktur gigi, yaitu suatu keadaan dimana hilangnya atau lepasnya fragmen dari satu gigi lengkap yang biasanya disebabkan oleh trauma atau benturan.



3.3 Ekstraksi Gigi Pencabutan gigi (Ekstraksi) merupakan tindakan bedah minor yang sering dilakukan dan menimbulkan luka pada soket gigi dan tulang alveolar. Proses penyembuhan tulang alveolar pasca pencabutan gigi merupakan hal yang penting untuk perawatan dental, terutama jika setelah pencabutan gigi akan dilakukan perawatan lanjutan seperti pemasangan protesa (implan atau gigi tiruan jembatan) dan perawatan ortodontik (Dharmaet al., 2010; Haghighat et al., 2011; Zhanget al., 2012). Meskipun tujuan utama dari dentistry harus pemeliharaan gigi, untuk alasan yang berbeda-beda, pencabutan gigi mungkin pilihan terbaik dari masing-masing yang terkena masalah klinis. Selain itu, pencabutan gigi adalah jauh prosedur bedah mulut yang paling umum dilakukan di manusia (Batenburg et al., 2000) dan hewan domestik seperti kuda, anjing, kucing, Lagomorpha (kelinci) dan tikus (Gaughan, 1998; Bellows, 2004).



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Indikasi umum untuk menghilangkan gigi cukup mirip dalam semua spesies dan termasuk pulpitis atau infeksi periapikal yang disebabkan oleh kerusakan gigi atau terbukanya pulpa traumatis, penyakit periodontal yang parah (Scheels and Howard, 1993; Legendre, 1994; Dixon, 1997a; Wiggs and Lobprise, 1997a; Sullivan, 1999; Alsheneifi and Hughes, 2001; Richards et al., 2005). 3.4 Scaling Gigi Scaling atau pembersihan karang gigi adalah proses untuk menghilangkan atau membersihkan kalkulus dan plak yang menumpuk pada gigi. Seiring perjalanan waktu, plak yang menumpuk akan dapat menyebabkan gusi menjadi meradang dan berdarah. Jika tidak dibersihkan, radang ini akan mengarah pada tahap awal penyakit gusi yang disebut gingivitis.



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BAB IV PEMBAHASAN



4.1 Managemet Pre-Operasi Management pre – operasi yang perlu dipersiapkan pada operasi ektraksi dan scaling gigi adalah : 1. Persiapan Alat dan Bahan Alat yang digunakan adalah termometer, stetoskop, timbangan, grafik gigi untuk kucing, endotracheal tube ukuran 2 mm, IV catheter 24G, reader kimia darah VetScan® versi 2, hematology analyzer VetScan® HM 5, tabung vakum dengan antikoagulan heparin, dan tabung vakum tanpa antikoagulan, alat-alat dental scaling dan dental extraction meliputi elevator, extraction forceps, probe, ultrasonic scaler, sharp scaler, bor gigi, polisher, curette, hook explorer, dan 3-ways syringes (Holmstrom et al. 2013a). Bahan yang digunakan adalah atropine sulfat, ketamine, xylazine, anastetikum gas isofluran, pet gel, chlorhexidine rinse, fluoride, NaCl, benang polyglycoli acid 4/0 dan jarum regular taper point ½ circle 2. Pemeriksaan Fisik Hewan Hewan diperiksa keadaan fisiknya. Pemeriksaan ini bertujuan untuk mengetahui keadaan fisik hewan, perubahan yang terjadi dan evaluasi preanestesi.



Pemeriksaan



fisik



meliputi



pengukuran



berat



badan



menggunakan timbangan, pengukuran suhu tubuh hewan menggunakan termometer, menghitung frekuensi napas dan frekuensi jantung per menit menggunakan stetoskop. 3. Pemeriksaan Keadaan Gigi Gigi hewan diperiksa satu persatu dan hasilnya dicatat pada diagram gigi Pemeriksaan dimulai dari mencatat gigi yang telah hilang dilanjutkan dengan penilaian calculus pada masing-masing permukaan gigi. Pemeriksaan selanjutnya adalah pemeriksaan indeks gingivitis dan sulcus gingivitis. Sulcus



8



gingivitis diperiksa dengan bantuan probe. Gingival resection diperiksa dengan bantuan probe. Furcation diperiksa dengan bantuan hook explorer. 4.2 Tindakan Anestesi Anestesi dilakukan dengan pemberian premedikasi terlebih dahulu melalui rute subkutan. Premedikasi yang digunakan adalah atropin sulfat. Atropin sulfat adalah sediaan anti kolinergik. Atropin sulfat digunakan untuk mencegah terjadinya bradikardia. Kombinasi ketamine dan xylazine diberikan untuk anestesi umum melalui rute intravena. Kombinasi ketamine dan xylazine digunakan karena ketamine memiliki efek samping terjadinya kekakuan otot dan xylazine merupakan sediaan yang dapat merelaksasikan otot Saat hewan mulai hilang kesadarannya, endotracheal tube ukuran 2 mm dipasang pada hewan. Pemasangan endotracheal tube dibantu dengan laryngoscope untuk melihat posisi epiglotis. Tanda bahwa endotracheal tube masuk pada saluran pernapasan adalah hewan sedikit tersedak dan keluar udara melalui lubang endotracheal tube. Isofluran sebagai anestesi per inhalasi diberikan setelah endotracheal tube terpasang. Maintenance isofluran dilakukan sepanjang proses operasi penyakit periodontal. Tujuan dari pemasangan endotracheal tube adalah untuk mempermudah proses maintenance anestesi secara per inhalasi. Sediaan anestesi per inhalasi yang digunakan adalah isofluran. Isofluran digunakan karena induksinya yang halus dan cepat, pemulihannya yang cepat, dan kelarutannya dalam darah rendah (Capey 2007).



4.3 Teknik Operasi 4.3.1 Ekstraksi Gigi Contoh teknik operasi ekstrasi gigi sebagai berikut : Pasien merupakan seekor anjing Corgi berusia empat tahun yang mengalami fraktur premolar keempat disertai dengan adanya tartar. Pasien diperiksa kondisi fisik secara umum lalu dianastesi kemudian pasien diletakan di meja operasi dengan posisi dorsal recumbency, lalu masukkan endotracheal tube ke mulut pasien.



9



Gambar 4. Fraktur premolar keempat disertai dengan adanya tartar



Gusi diinsisi terlebih dahulu dari depan ke belakang untuk membuat suatu penutup yang dapat dijahit setelah gigi diekstraksi.



Gambar 5. Gusi diinsisi



Periosteal elevator digunakan untuk memisahkan gusi dengan tulang rahang. Hal ini dilakukan untuk lebih mudah mengakses akar gigi dan mempertahankan kualitas penutup saat proses penyembuhan.



Gambar 6. Pemisahan gusi dengan tulang rahang 10



Gigi premolar keempat merupakan gigi terbesar pada anjing, sehingga harus dibelah terlebih dahulu untuk memudahkan proses pencabutan serta meminimalisir kerusakan pada tulang rahang dan gusi. Saat gigi sudah terbelah, setiap potong gigi beserta akarnya dapat dilepas dari gusi dan rongga gigi dengan menggunakan extraction forcep.



Gambar 7. Pencabutan gigi



Setelah gigi dicabut, pediatric drill digunakan untuk menghaluskan tepi alveolar (rongga gigi).



Gambar 8. Penghalusan tepi alveolar dengan pediatric drill



11



Gusi dijahit dengan menggunakan benang monocryl ukuran 4.0 dengan pola jahitan simple interrupted.



Gambar 9. Penjahitan gusi Setelah gusi dijahit, hal terakhir yang dilakukan adalah mebersihkan sisa – sisa tartar yang terdapat di seluruh gigi.



Gambar 10. Kondisi mulut pasien setelah dioperasi



4.3.2 Scaling Gigi Pasien merupakan seekor anjing Labrador berusia tiga tahun yang mengalami tartar dan plak diseluruh gigi. Pasien diperiksa kondisi fisiknya secara umum lalu dianastesi kemudian pasien diletakan di meja operasi dengan posisi dorsal recumbency, lalu masukkan endotracheal tube ke mulut pasien. Setelah pasien teranastesi, dilakukan pemeriksaan secara menyeluruh terhadap gigi pasien.



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Gambar 11. Pemeriksaan gigi pasien



Gambar 12. Pemeriksaan gigi pasien dengan dental X-Ray Plak dan tartar pada bagian bawah dan atas gusi serta di permukaan dan bagian belakang gigi dibersihkan dengan menggunakan alat dental scaler.



13



Gambar 13. Pembersihan plak dan tartar menggunakan dental scaler Setelah tartar dan plak pada gigi dibersihkan, gigi dipoles untuk membersihkan plak residual dan menghaluskan permukaan gigi. Hal terakhir yang dilakukan adalah penambahan fluoride pada gigi pasien sehingga gigi pasien lebih kuat dan tidak cepat berlubang.



Gambar 14. Pemolesan gigi



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Gambar 15. Penambahan fluoride 4.4 Management Pasca Operasi Setelah operasi, hal – hal yang perlu dilakukan adalah memberikan obat analgesia serta antiseptic oral gel (zinc ascorbate) dapat diberikan selama lima sampai tujuh hari untuk mengurangi rasa sakit serta mencegah infeksi. Pakan yang diberikanpun harus pakan yang konsistensinya lembut, hal ini dapat dilakukan selama dua minggu hingga kondisi pasien kembali seperti semula, Jika terjadi perdarahan pada mulut, pemilik harus segera membawa pasien ke dokter hewan.



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BAB V SIMPULAN DAN SARAN 5.1 Simpulan Pencabutan gigi (Ekstraksi) merupakan tindakan bedah minor yang sering dilakukan dan menimbulkan luka pada soket gigi dan tulang alveolar. Sedangkan Scaling atau pembersihan karang gigi adalah proses untuk menghilangkan atau membersihkan kalkulus dan plak yang menumpuk pada gigi. Seiring perjalanan waktu, plak yang menumpuk akan dapat menyebabkan gusi menjadi meradang dan berdarah. Sebelaum dilakukan ekstraksi maupun Scaling dilakukan management pre –operasi, yang perlu dipersiapkan pada operasi ektraksi dan scaling gigi adalah dengan pemeriksaan fisik dan gigi hewan, serta persiapan alat dan bahan. Kemudian dilakukan Anestesi dengan pemberian premedikasi terlebih dahulu melalui rute subkutan. Premedikasi yang digunakan adalah atropin sulfat. Teknik operasi yaitu Ekstraksi dan Gigi Scaling Gigi. Setelah operasi, hal – hal yang perlu dilakukan adalah memberikan obat analgesia serta antiseptic oral gel (zinc ascorbate) dapat diberikan selama lima sampai tujuh hari untuk mengurangi rasa sakit serta mencegah infeksi. 5.2 Saran Apabila hewan peliharaan pembaca mengalami tanda – tanda klinis penyakit gigi seperti bau mulut, kurang nafsu makan, gigi patah atau lepas, perdarahan dari mulut, gigi berubah warna, serta pembengkakan di sekitar daerah mulut, segera konsultasikan ke dokter hewan terdekat untuk mengetahui terapi lebih lanjut. Pemberian pakan hewan yang sesuai juga dapat dilakukan untuk mengurangi resiko terbentuk plak atau tartar, serta menggosok gigi hewan dengan pasta gigi khusus hewan sehari sekali dapat dilakukan untuk menjaga kesehatan gigi hewan sehingga terhindar dari penyakit.



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DAFTAR PUSTAKA



Capey S. 2007. The Comprehensive Pharmacology. Philadelphia (US): Elsevier Science. hlm 1–4. Fernandes LA, Martins TM, Almeida JMD, Nagata MJH, Theodoro LH, Garcia VG, Bosco AF. 2010. Experimental periodontal disease treatment by subgingival irrigation with tetracycline hydrochloride in rats. J Appl Oral Science. 18(6):635-40. doi: 10.1590/S1678-77572010000600017. Gawor JP, Reiter AM, Jodkowska K, Kurski G, Wojtacki MP, Kurek A. 2006. Influence of diet on oral health in cats and dogs. J Nutrition. 136(7):2021– 2023. Kortegaard HE, Eriksen T, Baelum V. 2014. Screening for periodontal disease inresearch dogs a methodology study. ActaVetScand. 56(1):77.Doi:10.1186/s13028-014-0077-8. Kyllar M, Witter K. 2005. Prevelence of dental disorders in pet dogs. Original Paper Vet. Med 50, 11:496-505 Perrone JR. 2013. Small Animal Dental Procedures for Veterinary Technicians and Nurses. Iowa (US): J Wiley. hlm 4, 5, 14, 15, 25, 26, 96, 97. . Reiter, Alexander M and Maria M Soltero-Rivera. 2014.”Applied Feline Oral Anatomy And Tooth Extraction Techniques. Journal of Feline Medicine and Surgery.16, 900–913



17



LAMPIRAN



18



Original Paper



Vet. Med. – Czech, 50, 2005 (11): 496–505



Prevalence of dental disorders in pet dogs M. Kyllar1, K. Witter2 1



Institute of Anatomy, Histology and Embryology, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic



2



Institute of Histology and Embryology, Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria



ABSTRACT: Oral disorders of the dog represent for veterinarians a medical challenge and an important field of interest from the economical point of view. Although many epidemiological studies on dental diseases in beagles bred under controlled conditions have been realized, information on frequency of these alterations in populations of pet dogs, especially in Central Europe, is far from complete. The aim of our study was to assess the prevalence of the most common oral diseases in dogs in a Czech urban region. A total number of 408 dogs, presented at a private Czech urban veterinary hospital for different reasons, were analyzed. Site specificity and severity of dental diseases were assessed using modified indexing systems. Dental alterations could be found in 348 out of 408 dogs (85.3%). The most frequent diseases were (i) periodontitis (60.0% of 408 dogs), (ii) calculus (61.3%), (iii) missing teeth (33.8%), and (iv) abnormal attrition (5.9%). Furthermore, single cases of caries, tumors and enamel hypoplasia could be observed. Periodontitis occurred preferentially in the upper jaw of small dogs and increased with age. The labial/buccal side of teeth was affected more severely than the lingual/palatinal side. Differences between left and right side could not be observed. Malocclusion and insufficient oral hygiene care seem to predis-pose to periodontitis. As periodontitis, dental calculus occurred preferentially in small dogs and increased with age. The prevalence of calculus formation did not differ between left and right side. However, the upper jaw showed a higher degree of affection than the mandible. On the labial/buccal side of the teeth, a thicker calculus layer could be observed than lingually/palatinally. Interestingly, the degree of calculus formation and of periodontitis did not correlate in all cases, supporting the hypothesis that supragingival calculus per se is not an irritant. The pattern of tooth loss was the same between left and right side and between upper and lower jaw. Most commonly, the first premolars were missing followed by incisors and other premolars and molars. Tooth loss for other reasons than periodontitis and single cases of tooth agenesis has not been detected in our study. (Abnormal) tooth wear was detected only in older dogs and affected mostly canines and premolars of large breeds. Age estimation based on dental attrition should be carried out with care, because tooth wear depends on keeping conditions and feeding of the dog. Our study confirmed the high prevalence of oral diseases in dogs. Veterinarians could improve the effectiveness of treatment concentrating their diagnostic efforts on age groups and types of teeth at highest risk, as assessed in this and other reports.



Keywords: periodontitis; periodontal disease; calculus; missing teeth; tooth loss; attrition; tooth wear; diagnosis



Oral disorders are of major clinical importance in the dog. From a survey made in the United States resulted that only 7% of the dog population can be considered healthy (Lund et al., 1999). Epidemiological studies have shown that periodontal disease and dental calculus are the most common oral diseases in the dog (Page and Schroeder, 1981; DeMeijer et 496



al., 1991; Hoffmann and Gaengler, 1996; Harvey, 1998; Lund et al., 1999). Other important altera-tions are missing teeth, (abnormal) attrition, caries and tumors (Hale, 1998; Lund et al., 1999). Periodontal disease is the predominant disorder of the oral cavity not only in dogs, but also in other animals (Page and Schroeder, 1982; Genco



Vet. Med. – Czech, 50, 2005 (11): 496–505



Original Paper



et al., 1998). They are mostly considered diet-related disorders (Krasse and Brill, 1960; Page and Schroeder, 1982; Genco et al., 1998; Gorrel, 1998; Harvey, 1998; Lund et al., 1999). A soft diet causes accumulation of bacterially colonized den-tal plaque. Periodontal inflammation is a process affecting the tissues surrounding the tooth. It is induced either experimentally or occurs sponta-neously, and is correlated to the occurrence of gingival inflammation. The lack of oral hygiene causes plaque deposition and calculus formation, which harbors the bacteria and eventually induces gingival inflammation (Lindhe et al., 1975; Page and Schroeder, 1982). It has been suggested for a long time that these disorders are detrimental only to the oral cavity. However, recently showed some studies a close association of these disorders with the general health of the animal. The per-sistent infection of the oral cavity does not only discomfort the affected animal, but may also cause diseases of distant organs (DeBowes et al., 1996). Overt bacterial infections are seen only rarely, but the inflammatory response, which they elicit in the gingival tissue, is ultimately responsible for a progressive loss of collagen attachment of the tooth to the underlying alveolar bone. The conse-quence is the loosening or even loss of the tooth (Loesche and Grossman, 2001). While feeding soft diets has recently become very popular with dog owners, proper oral hygiene care (e.g., tooth brushing), which is proven to prevent effectively periodontal and other oral diseases, is rarely provided (Hamp and Loe, 1973; Lindhe et al., 1973; Hennet, 2002).



Oral tumors account for six percent of all canine tumors. The most frequent oral tumor is the squamous cell carcinoma (20% of oral tumors), followed by fibrosarcoma (10%), and other oral neoplasms (Ramos-Vara et al., 2000) Oral disorders in the dog represent for veterinarians both a medical challenge and an important field of interest from the economical point of view. Therefore, in dogs have been realized numerous studies on periodontal disease with large param-eters (Heijl and Lindhe, 1980; Syed et al., 1980; Newes et al., 1997; Hennet, 1999). However, most of them deal with beagle dogs bred in controlled environment (Rosenberg et al., 1966; Saxe et al., 1967; Lindhe et al., 1975), whereas information on oral disorders in pets is far from complete. Site prevalence and severity of affections is assessed only rarely. Available extensive epidemiological studies concerning dental disorders in humans could serve as a model for such research in animals (Genco et al., 1998). The purpose of this retrospective study was to document the prevalence of the most common oral diseases in dogs that were presented at a Czech urban veterinary hospital and to assess which teeth are preferentially affected. The results of this study should alert practitioners to the main oral problems of dogs and help to communicate with the clients/pet owners regarding these important disorders.



A decrease of tooth number in dogs can be caused by agenesis (mostly in small, brachycephalic breeds) or by tooth loss in consequence of periodontal disease or mechanical affection. Mostly are lost the lower third molar, upper and lower first premolar and the incisors, usually due to periodontal disease (Harvey et al., 1994). The lower first premolars are often missing in young dogs, usually due to agen-esis (Harvey et al., 1994; Hoffmann and Gaengler, 1996).



Animals



Abnormal attrition is mostly observed in work-ing dogs, in dogs fed a hard diet, in dogs that love to play with stones, and in so called “wire-biters” (Van Foreest and Roeters, 1998) Dental caries is a rare disease compared to other dental disorders in the dog. The teeth most commonly involved are the last premolar and the first molar teeth (Hale, 1998).



MATERIAL AND METHODS



This study was realized during the period of 2003– 2004. A total number of 408 dogs, which had been presented at a private Czech urban veterinary hospital for different reasons, was analyzed for al-terations of the oral cavity. The dogs were classified into groups according to their age (as reported by the owners): 1– 4 years of age, 5–8 years of age, 9–11 years of age, 12–13 years of age; and accord-ing to their size: small breeds of less than 10 kg, medium sized breeds 10–30 kg, and large breeds of more than 30 kg body mass (Table 1). The standard tooth formula of the permanent dentition of the dog, which was used for determination of miss-ing teeth and sites of other pathological changes of the dentition, is I3/3, C1/1, P4/4, M2/3 (Page and Schroeder, 1982). 497



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Vet. Med. – Czech, 50, 2005 (11): 496–505



Table 1. Age and size distribution of the examined dogs (number of the dogs) Age groups



Small breeds



Medium breeds



Large breeds



1–4 years



67



66



14



5–8 years



49



53



21



9–11 years



43



42



15



12–13 years



22



9



7



Total number



181



170



57



Clinical examination and classification of oral disorders Each dog was examined clinically. Number and localization of teeth, degree and localization of periodontal disease, dental calculus, dental wear (attrition), dental caries and any other alterations of the oral cavity were recorded. Periodontal disease, formation of dental calcu-lus and crown abrasion were scored according to a modified indexing system commonly used in the man.



In human dentistry, alterations of the periodon-tium are measured using the well accepted Silness and Loe plaque index (Loe and Silness, 1963), which is based on evaluation of plaque accumulation and gingival inflammation. This indexing system was used in this study with slight modifications as fol-lows, (0) Healthy gingiva without signs of gingivi-tis, probing depth 0.0–1.0 mm; (1) Gingivitis with slight swelling and mucosa turning reddish, probing depth 0.0–1.0 mm; (2) Early periodontal disease with swelling and mucosa turning reddish, probing depth less than 2.5 mm; (3) Moderate periodontal



Figure 1. Stages of periodontal disease according to the Silness and Loe plaque index. (A) Stage 0, Healthy gingiva. Gingiva clinically not inflamed, firm, pale pink in color (unless pigmented), minimal dental deposits (plaque and calculus). No bleeding on gentle probing, probing depth 0.0–1.0 mm. (B) Stage 1, Gingivitis. Slight swelling of the gingiva, hyperemia, color of turning reddish. Slight bleeding on probing, probing depth 0.0–1.0 mm. (C) Stage 2, Early periodontitis. Gingiva swollen and red due to severe hyperemia. Teeth usually with dental deposits (redundant plaque and/or calculus). Bleeding on probing, probing depth 1.0–2.5 mm. (D) Stage 3, Moderate periodontitis. Inflamed gingiva, teeth with dental deposits. Bleeding on probing, probing depth up to 5.0 mm. The gingival mar-gins begin to recede. (E) Stage 4, Severe periodontitis. Signs of clearly inflamed gingiva. Gingival recession results in visible root surfaces and furcation involvement. Probing depth either more than 5.0 mm or very low due to a receded gingiva



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disease with swelling and red mucosa, often with hemorrhages, probing depth of less than 5.0 mm; (4) Severe periodontal disease with red and swollen mucosa, alveolar bone loss, probing depth more than 5.0 mm (Figure 1). The degree of gingival inflammation was examined separately for each tooth class region (e.g. incisor, premolar, molar region) and for labial/buccal and lingual/palatinal side. Formation of dental calculus was examined and scored by a calculus indexing system (Greene and Vermillion, 1964) as follows, (0) No dental calculus; (1) Supragingival calculus covering less than one third of crown surface; (2) Supragingival calculus covering more than one third but less than two thirds of the dental crown; (3) Supragingival cal-culus covering more than two thirds of the dental crown. Dental calculus was examined separately on both labial/buccal and lingual/palatinal surfaces of the teeth.



Tooth crown abrasion was classified as follows, (0) No abrasion of the dental crown; (1) Abrasion of less than one third of the crown; (2) Abrasion of more than one third of the crown. In addition, all dogs, if possible, were checked for history of dental treatment and its details.



RESULTS A total of 348 out of 408 dogs (85.3%) presented to the small animal clinic showed dento-gingival alterations. In some but not all cases, these alterations were the reason why the owners did consult a veterinarian. The following dental and gingival alterations could be observed: (i) periodontal disease (60.0% of 408 dogs), (ii) calculus (61.3% of 408 dogs), (iii) missing teeth (33.8% of 408 dogs), and (iv) abnor-



Table 2. Prevalence of dental disorders in pet dogs presented at a Czech urban veterinary hospital for different reasons in dependence on age and body size Prevalence of dental disorders (%) Age groups Small breeds



Middle breeds



Large breeds



Total



1–4 years



53.7



31.8



21.4



40.8



5–8 years



68.1



47.2



42.8



53.6



9–11 years



86.0



88.1



66.6



85.0



12–13 years



90.1



88.8



85.7



89.4



1–4 years



53.7



48.5



28.6



48.9



5–8 years



57.2



58.5



42.9



55.2



9–11 years



76.7



85.7



60.0



78.0



12–13 years



81.8



88.8



85.7



84.2



1–4 years



22.4



19.7



7.1



19.7



5–8 years



28.6



41.5



0.0



29.3



9–11 years



51.2



59.5



40.0



53.0



12–13 years



54.5



55.5



42.8



52.6



1–4 years



0.0



0.0



0.0



0.0



5–8 years



0.0



0.0



28.5



4.9



9–11 years



4.6



19.0



25.0



14.0



12–13 years



0.0



22.2



28.5



10.5



Periodontal disease



Dental calculus



Missing teeth



Dental attrition



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Vet. Med. – Czech, 50, 2005 (11): 496–505 *ODJTPS SFHJ PO $BOJOF SFHJ PO



Upper jaw



1SFNPMBS SFHJ PO



Figure 2. Prevalence and localization of periodontal disease in dogs (age group 1–4 years) assessed by a perio-dontal indexing system



Number of dogs (out of 147)



.PMBS SFHJPO



Periodontal index (degree) 0



0



1



2



3



4



20 40 60 80



Lower jaw



mal attrition (5.9% of 408 dogs). The prevalence of these diseases depending on age and size of the dogs is shown in Table 2. Furthermore, there were single cases of dental caries, tumors and enamel



hypoplasia. These cases were so rare that they were not further analyzed. Alterations of the periodontium represented the most common oral disease in the dogs under study 60



Upper jaw



Number of dogs (out of 123)



* ODJTPS SFHJP O $ BOJOF SFHJP O 1SFNPMBS SFHJ PO . PMBS SFHJPO



Periodontal index (degree)



0



1



2



0



20



40 Lower jaw



3



4



Figure 3. Prevalence and localization of periodontal disease in dogs (age group 5–8 years) assessed by a periodontal indexing system



500



Vet. Med. – Czech, 50, 2005 (11): 496–505



Original Paper *ODJTPS SFHJ Figure 4. Prevalence and localization PO of periodontal disease in dogs (age $BOJOF SFHJ group 9–11 years) assessed by a perPO 1SFNPMBS SFHJ iodontal indexing system PO



Upper jaw 40 -



Number of dogs (out of 100)



30 -



.PMBS O



SFHJP



20 -



10 0-



Periodontal index (degree)



0



1



2



3



4



0 10 20 30 40 Lower jaw 50



where 245 out of 348 dogs with dento-gingival disorders were found to be positive. Differences between left and right jaw quadrant could not be observed. The frequency of periodontal alterations as well as the degree of inflammation increased with age. Earliest signs occurred first in small breed dogs. Figure 1 shows typical features of gingival inflammation scored as degree (0), (1), (2), (3) and (4) in the examined dogs. The single degrees of periodontal disease were represented by increasingly swollen and reddish gingiva and deep gingival sulci, sometimes with soft deposits. Radiographs, which were made in some severe cases of periodontal disease, revealed in every case a certain degree of alveolar bone loss. Assessment of the Silness and Loe index of periodontal disease revealed that the labial/buccal surface of the tooth was more affected than the lingual/palatinal surface. Periodontal alterations and gingival inflammation started mostly in the premolar region of both upper and lower jaw and spread with increasing age first to the molars and later to other regions of the jaws (Figures 2–5). Periodontal disease was more frequent and more severe in the upper jaw in comparison with the mandible (Figures 2–5). Dental calculus in young age was observed mostly in small dogs. The degree of dental calculus in-



creased with the age of the animal (Table 2). The prevalence of calculus formation did not differ between left and right side, however, it did differ between upper and lower jaws with a higher degree of affection of the upper jaw. Generally, on the labial/buccal side of the teeth, thicker calculus layers could be observed than lingually/palatinally. The distribution pattern of dental calculus index was about the same between the left and right side and between upper and lower jaw. However, the dental calculus index was lower in large dogs compared to small dogs and increased with age. Tooth loss increased with age (Table 2) and with increasing degree of gingival inflammation. The pattern of tooth loss was about the same between left and right side and between upper and lower jaw. The teeth most commonly missing were the first premolars followed by incisor teeth and then by other premolars and molars. Premolars followed by incisors were most often missing in small sized breeds. Medium sized breeds often lost premolar and molar teeth, in contrast to large sized breeds, where only premolar teeth were frequently miss-ing. The sites of missing teeth correlated with the sites of periodontal disease. There were only single cases of tooth agenesis in young dogs. Dental attrition was observed only in older dogs. Abrasion increased with age, in single cases reach-



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Vet. Med. – Czech, 50, 2005 (11): 496–505



*ODJTPS SFHJ PO



$BOJOF SFHJ PO



Figure 5. Prevalence and localization of periodontal disease in dogs (age group 12– 13 years) assessed by a periodontal indexing system



Upper jaw



Number of dogs (out of 38)



1SFNPMBS SFHJ PO .PMBS SFHJP O



Periodontal index (degree)



0



1



2



3



4



0



10



Lower jaw 20



ing degree 2 in dogs older than eight years of age. Large breeds were generally more affected than small and middle breeds (Table 2). Tooth wear did neither differ between left and right side nor be-tween upper and lower jaw. Abrasion started in canines and premolars. These teeth were also most severely affected. The percentage of dogs that had received home oral hygiene care was very low. It mostly consisted of daily tooth brushing using a tooth paste designed for animals and regular scaling of dental calculus by veterinary surgeons.



DISCUSSION This study aimed to assess the prevalence of oral diseases of pet dogs in a Czech urban region. Periodontal disease, dental calculus and tooth loss were the most frequent alterations found in this study. Similar results were also reported by other authors (Lindhe et al., 1973; Page and Schroeder, 1982; DeMeijer et al., 1991; Harvey et al., 1994; Hoffmann and Gaengler, 1996; Genco et al., 1998; Gorrel, 1998; Harvey, 1998; Lund et al., 1999). Additionally, our study revealed few cases of other oral disorders such as oral tumors, enamel hypoplasia, tooth attrition and dental caries, which have also been described to be found in dog populations (DeMeijer et al., 1991; Lund et al., 1999).



Interestingly, recent studies (DeMeijer et al., 1991; Hoffmann and Gaengler, 1996; Harvey, 1998; Lund et al., 1999) reveal in general a higher prevalence of oral disorders in dogs compared to older studies, which concerned, however, mostly beagle colonies (e.g., Rosenberg et al., 1966; Saxe et al., 1967). This can be explained either as a re-sult of increasing prevalence of these disorders or as a virtual increase, because veterinary clinicians are more often requested for dental treatments in dogs. It might be also a misinterpretation because of different approaches to epidemiological studies (Preshaw et al., 2004). Periodontal disease seems to be one of the most common oral disorders in small animals (Gorrel, 1998). We observed an increasing prevalence and severity of periodontal disease with increasing age of the dogs. These findings are in agreement with previous experimental studies on beagle colonies (Rosenberg et al., 1966; Saxe et al., 1967) as well as with retrospective studies in pet dogs (Harvey et al., 1994; Hoffmann and Gaengler, 1996; Harvey, 1998; Lund et al., 1999). Interestingly, these studies revealed that the disease develops spontaneously in dogs fed with both homemade and commercial-type diet.



We observed a higher frequency and earlier onset of periodontal disease in small breed dogs compared to large breeds. This state could be explained by genetic predisposition, which render the gingiva more susceptible to periodontal disease. Also malocclu-



502



Vet. Med. – Czech, 50, 2005 (11): 496–505 sions, which are very common in small breeds, expose the teeth to deposition of subgingival plaque resulting in periodontal disease. Some reports show that all dogs older than 5 years of age suffer from some degree of periodontal disease (e.g., Hamp and Loe, 1973; Hoffmann and Gaengler, 1996). The most often inflamed site of gingiva in dogs is apparently the premolar region followed by the molar and then the incisor region. The labial/buccal gingiva is more affected than the lingual/palatinal gingiva. In contrast to the dog, the molar region is most predilected for periodontal disease in the hu-man (Loesche and Grossman, 2001; Newman and Carranza, 2002), probably because it is difficult to remove plaque by simple brushing in this region (Newman and Carranza, 2002). Dogs usually do not receive oral hygienic treatment. According to our study, the gingiva seems to be more often inflamed in the upper jaw than in the mandible. These results are, however, in contradiction with most other reports (Hamp and Loe, 1973; Harvey et al., 1994; Hoffmann and Gaengler, 1996) indicating the same prevalence in both areas. Development of periodontal disease varies at different sites. The same dentition may show both normal sites and sites with gingivitis and perio-dontal disease. For planning and evaluation of the effect of treatment, diagnosis should be therefore site specific (Harris, 2003). In our study, there were no differences between right and left side, but be-tween the individual tooth regions. The sites of most severe affection differed in dependence on the animal group. Simple periodontal disease indicators (scores) allowing to choose appropriate treatment methods and to predict clinical outcome, which are suitable for the screening of large animal populations, are still lacking (Harvey et al., 1994). Whether index-es adapted from human medicine (e.g., Loe and Silness, 1963) will be helpful remains to be tested. Biopsy of apparently diseased tissue followed by histological examination might be useful as an ad-ditional diagnostic tool (Johnson et al., 1988). Accumulation of dental calculus increases, similarly as periodontal disease, with the age of the animal. Our study revealed that dental calculus appeared in some small breed dogs as early as at one year of age. These dogs had persistent deciduous teeth, which caused malocclusion and thus cre-ated an optimal surface for plaque accumulation. According to Rosenberg et al. (1966), the pattern of calculus formation matches the inflammation



Original Paper status of the periodontal tissue. These authors observed that about 95% of pet dogs fed either a homemade or commercial type diet show heavy calculus deposition at the age of 26 months and that the gingival inflammation becomes more severe with increasing age. However, calculus itself does not seem to be an irritant. In fact, it has been shown that under certain conditions a normal attachment may be seen between the junctional epithelium of the gingiva and calculus (Fitzgerald and McDaniel, 1960). Autoclaved calculus can be encapsulated in connective tissue without causing marked inflammation (Allen and Kerr, 1965). Our study supports this information, since thick calculus deposits have been found in many examined dogs with only a light degree of gingival inflammation. Apparently, supragingival calculus per se is not directly involved in the etiology or even pathogenesis of periodontal disease and is mainly of cosmetic significance if plaque is not too large (Lang et al., 1997). However, plaque can be indirectly responsible for gingival inflammation as a result of the immune response of the host (Bascones et al., 2004). Loosening of teeth and following tooth loss is often elicited by inflammatory response in the gingival tissue, which leads to a progressive loss of collagen attachment of the tooth to the un-derlying alveolar bone (Loesche and Grossmann, 2001). Our study revealed a relatively large number of missing teeth in the examined dogs. The sites of missing teeth agreed with other reports (Page and Schroeder, 1981): the first premolars; then the other premolars and incisors, and finally molars en-suing. Interestingly, the sites of marked periodontal disease were similar to those of missing teeth. The number of missing teeth increased with the pro-gression of periodontal inflammation and with age, suggesting a causal relationship between these two alterations (Page and Schroeder, 1982). Tooth loss for other reasons than periodontal disease or tooth agenesis has not been detected in our study. Some studies present also other causes of missing teeth, such as traumatic tooth loss (Bittegeko et al., 1995; Dole and Spurgeon, 1998). Attrition of teeth becomes apparent in older dogs (older than eight years of age). The age of dogs can be estimated based on the degree of dental attri-tion. This method is, however, highly speculative, because tooth wear depends on feed and keeping conditions (Berglundh et al., 1991). In agreement with a previous report (Hoffmann and Gaengler, 1996), our study revealed no den503



Original Paper tal caries in the examined dogs. The scarcity of dental caries contrasts with the high prevalence of periodontal disease and calculus formation. The reason is unexplained at present. It is speculated that the oral condition of the dog including the oral bacterial flora may be suitable rather for the development of periodontal disease than for dental caries formation (Gorrel, 1998; Hale, 1998). The anatomical conformation of the tooth crown and the thicker layer of enamel compared to human teeth could be another reason. However, there is no evidence to support this assumption so far. Our study as well as many others showed the high prevalence of oral diseases in dogs and confirmed that periodontal disease is the most common oral condition in dogs. It is well known from human studies that a majority of dental disorders can be prevented by daily oral hygiene. Periodontal disease is almost always significantly associated with the overgrowth of bacteria in the subgingival plaque. This overgrowth can be periodically suppressed by mechanical periodontal debridement. The oral flora can also be altered by the judicious use of antimicrobial agents (Loesche and Grossman, 2001). Appropriate instructions concerning dental hygiene to the pet owners should be helpful to lower the incidence of dental disorders in a dog population. Clinicians could also improve the effectiveness of treatment concentrating their diagnostic efforts on age groups and types of teeth at highest risk, as assessed in this and other reports. Follow-up studies will be necessary to test the effectiveness of pet owner education, training and alerting of veterinarians and improved dental hygiene care in a given dog population.



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Corresponding Author Michal Kyllar, Institute of Anatomy, Histology and Embryology, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Palackeho 1–3, CZ-612 42 Brno, Czech Republic Tel. +420 541 562 204, fax +420 541 562 217, e-mail: [email protected]



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APPLIED FELINE ORAL ANATOMY AND TOOTH EXTRACTION TECHNIQUES



An illustrated guide Alexander M Reiter and Maria M Soltero-Rivera



Practical relevance: Tooth extraction is one of the most commonly performed surgical procedures in small animal practice. Clinical challenges: The clinician must be familiar with normal oral anatomy, utilize nomenclature accepted in dentistry and oral surgery, use the modified Triadan system for numbering teeth, identify normal structures on a dental radiograph, understand the tissues that hold the teeth in the jaws, know the biomechanical principles of tooth extraction, be able to choose the most appropriate instrument for removal of a tooth, extract teeth using closed and open techniques, and create tension-free flaps for closure of extraction sites. Audience: This review is intended to familiarize both the general and referral practitioner with feline oral anatomy and tooth extraction techniques. Patient group: Tooth extraction is predominantly performed in cats with tooth resorption, chronic gingivostomatitis and periodontal disease. Equipment: The basic contents of a feline tooth extraction kit are explained. Evidence base: The guidance contained within this review is based on a combination of the published literature, the authors’ personal experience and the experience of colleagues.



Permanent teeth of young cats have a much wider pulp cavity and thinner dentinal walls compared with permanent



Feline oral anatomy Eruption and types of teeth The kitten’s 26 deciduous teeth erupt at between 2 and 6 weeks of age. The cat’s 30 permanent teeth erupt at between 3 and 6 months of age. Cats have incisors for cutting, prehending and grooming, canines for penetrating, grasping and defense, and cheek teeth (premolars and molars) for holding, carrying, breaking and tearing food. The maxillary fourth premolar and mandibular first molar are the carnas-sial teeth.1–3 Tooth structure Enamel covers the crown and cementum covers the root. These hard tissue layers meet at the cemento-enamel junction near the cervical



Figure 1 Radiographs of the mandibular incisors and canines, and the right mandibular cheek teeth in a cat less than



1 year of age (A and B) and in a cat over 3 years of age (C and D). E = enamel; PC = pulp chamber; D = dentin; RC = root canal; A = apex; MS = mandibular symphysis; AM = alveolar margin;



LD = lamina dura; PLS = periodontal ligament space; F = furcation; MC = mandibular canal



teeth of old cats. Alexander M Reiter Dipl Tzt Dr med vet DAVDC DEVDC* Maria M Soltero-Rivera DVM DAVDC Department of Clinical Sciences, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA, USA *Corresponding author: [email protected]



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R E V I E W / Oral anatomy and tooth extraction



To o t h f o r m u l a s a n d d i r e c t i o n a l t e r m s The anatomical names of teeth are (right or left), (maxillary or mandibular), (first, second, third or fourth), (incisor, canine, premolar or molar), as applicable, either written out in full or abbreviated.



Modified Triadan system The modified Triadan system numbers each jaw quadrant as follows:  Right maxillary quadrant 100 (500 when referring to deciduous teeth)   Left maxillary quadrant 200 (600 when referring to deciduous teeth)



 Left mandibular quadrant 300 (700 when referring to deciduous teeth)   Right mandibular quadrant 400 (800 when referring to  deciduous teeth) Beginning with the first incisor (01), teeth are numbered from mesial to distal along the dental arch. Evolutionarily missing teeth result in gaps in the numbering sequence (Figure 2). The maxillary first (05) premolars and mandibular first (05) and second (06) premolars are absent in the cat. The maxillary and mandibular canines (04), maxillary fourth premolars (08) and mandibular first molars (09) are large reference teeth that allow counting forward or backward when numbering all other teeth.1–3 Figure 2 Modified Triadan tooth numbering system for the maxillary



(A) and mandibular (B) permanent teeth in the cat



The directional terminology that is used is illustrated in Figure 3 and tabulated below.



Figure 3 Directional terminology for maxillary



(A) and mandibular (B) teeth in the cat. M = mesial; La = labial; B = buccal; D = distal; P = palatal; Li = lingual



Rostral



Towards the tip of the nose



Lingual



Facing the tongue



Caudal



Towards the tail



Palatal



Facing the hard palate



Ventral



Towards the lower jaw



Occlusal



Facing an opposing dental arch



Dorsal



Towards the top of the head or the muzzle



Coronal



Towards the tip of the crown



Mesial



Towards the midline along the dental arch



Apical



Towards the apex of a root



Distal



Away from the midline along the dental arch



Subgingival



Apical to the gingival margin



Labial



Facing the lip



Supragingival



Coronal to the gingival margin



Buccal



Facing the cheek



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portion of the tooth. dentin makes up the bulk of the mature tooth. The pulp cavity, which contains the pulp, is divided into the pulp chamber in the crown and the root canal(s) in the root(s). The feline pulp connects with periapical tissues through several foramina in the root apex (apical delta). Non-apical ramifications exist in the furcation and other areas of the root. odontoblasts at the pulp’s periphery produce dentin throughout life in a vital tooth. Therefore, permanent teeth of young cats have a much wider pulp cavity and thin-ner dentinal walls (Figure 1) compared with permanent teeth of old cats.1–3 incisors and canines are single-rooted teeth. Permanent maxillary second premolars and first molars often have two roots fused to each other (allowing them to be extracted without tooth sectioning). Permanent mandibular third and fourth premolars and first molars have two roots, while the maxillary fourth premolars have three roots. The two-rooted permanent maxillary third premolars occasionally have a third root.4 The furcation is where two or more roots meet at the crown.1–3



Bones, joints and muscles Mesaticephalic cats have a head of medium proportions. Persians are brachycephalic with a short, wide head. Siamese are dolichocephalic with a long, narrow head.



Figure 4 Different types of oral mucosa in the upper (A) and lower (B) jaws of a cat.



Note the unpaired incisive papilla immediately caudal to the maxillary first incisor teeth (arrowhead) and the lingual molar gland contained within a membranous pad caudolingual to the mandibular first molar tooth (arrow). The dotted line depicts the approximate course of the mucogingival junction



The upper jaw and face consist of the paired incisive bones, maxillae, palatine, nasal, zygomatic and temporal bones, and the unpaired vomer bone. The incisive bones carry the maxillary incisors, and the maxillae carry the maxillary canines, premolars and molars. The infraorbital canal contains the infraorbital artery, vein and nerve (sensory), and lies dor-sal to the maxillary fourth premolar and first molar; the neurovascular bundle exits the canal at the infraorbital foramen about 1 cm dorsal to the maxillary third premolar.1,3



The lower jaw consists of the paired mandibulae, carrying all the mandibular teeth. The mandibular canal contains the infe-rior alveolar artery, vein and nerve (sensory), which exit at the caudal, middle and rostral mental foramina. The mandibular symphysis,



Periodontium and oral mucosa The periodontium is made up of gingiva, periodontal ligament, cementum and alveolar bone. The inelastic gingiva attaches to the cervical portion of the tooth and most coronal portion of the alveolar bone. its most coronal edge is called the gingival margin. The space between the tooth and the free gingiva is the gingival sulcus, which should not be deeper than 0.5 mm in cats.3 The periodontal ligament attaches the root to alveolar bone. Cementum is produced by cementoblasts, and its width increases with age. Alveolar bone surrounds the alveolar socket. The most coro-nal edge of the alveolar bone is the alveolar margin. The periodontal ligament space appears radiographically as a dark line sur-rounding the root. immediately adjacent to it is the radiopaque lamina dura, an extension of cortical bone into the alveolus.2,3 Alveolar mucosa is elastic, faces the alveolar bone and is separated from the gingiva by the mucogingival junction. Labial and buccal mucosae cover the inside of the lip and cheek (Figure 4). Together with the tongue, the loose sublingual mucosa covers the floor of the mouth. The mucosa at the dorsal and ventral tongue surfaces contains many different papillae. The inelastic mucosa of the hard palate is firmly attached to the palatine processes of the maxillae and the palatine bones. Finally, the mucosa of the muscular soft palate contains small salivary glands. The oral mucosa is separated from the skin by the mucocutaneous junction.3



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a fibrocartilaginous synchondrosis, connects the two mandibles rostrally. The condylar process of the mandible and the mandibular fossa and retroarticular process of the temporal bone form the temporomandibular joint. The masseter, temporal and pterygoid (medial and lateral) muscles close the mouth. The digastricus muscles open the mouth.1,3 Lips and cheeks The upper and lower lips meet at the commissure. The dorsal and ventral buccal branches of the facial nerve (for motor innervation) run over the masseter muscle in a caudorostral direction into the cheek. Traversing in between the two nerves is the parotid duct, which opens into the mouth at the parotid papilla in the buccal mucosa near the maxillary fourth premolar.1–3 Palate The roof of the mouth is divided into non-elas-tic hard palate and elastic soft palate. The hard palate mucosa has several transverse ridges (palatine rugae). The unpaired incisive papilla is immediately caudal to the maxillary first inci-sor teeth. The paired major palatine arteries course from the major palatine foramina at the level of the maxillary fourth premolars rostrally to the palatine fissures. Palatoglossal folds emerge when the tongue is withdrawn from the mouth, running from the body of the tongue to the rostrolateral aspect of the soft palate.1,3



R E V I E W / Oral anatomy and tooth extraction



Indications for tooth extraction The most common indications for tooth extraction in cats include tooth resorption and stomatitis, followed by retained roots and teeth with periodontal or endodontic/periapical disease.6



Equipment, instruments and materials for tooth extraction Keeping a cat’s mouth open wide for a prolonged period of time can reduce maxillary artery blood flow, which may result in temporary or permanent blindness postanesthesia.7,8 Rather than using springloaded mouth gags, 30 mm or 20 mm plastic gags that are custom-made from a needle cap can be placed between maxillary and mandibular canines to enable adequate mouth opening for performance of extraction procedures (Figure 5). Air-powered systems are equipped with irrigating mechanisms to cool the burs used in high- and low-speed dental handpieces.9 High-speed handpieces are used for sectioning multi-rooted teeth into single-rooted crown–root segments and for removing and shaping alveolar bone; low-speed handpieces are used for cutting bone only. An assortment of round (to remove alveolar bone), cross-cut



Tongue The cat uses its muscular tongue to lap fluids, form food boluses and groom the fur. The rostral two-thirds are the body of the tongue; the caudal one-third is the root of the tongue. The rough dorsal tongue surface has firm papillae pointing caudally. The lingual frenulum connects the lingual body to the floor of the mouth. The mandibular and sublingual ducts open at the sublingual caruncles at the rostroventral base of the frenulum. The paired lingual arteries supply the tongue. The lingual and facial nerve provide sensory function, while the hypoglossal nerve is responsible for motor function.1,3



Salivary glands, lymph nodes and tonsils Cats have four pairs of major salivary glands (parotid, sublingual, mandibular and zygomatic). Scattered glandular tissue is present submucosally in the lips, cheeks and soft palate. Caudolingual to each mandibular first molar tooth is a small lingual molar gland contained within a membranous pad.2,5 There are three lymph centers in the head (parotid, mandibular and retropharyngeal). The pala-tine tonsils are attached to the dorsal aspect of the lateral pharyngeal walls, which are also called the fauces.1–3



Figure 5 (A) Spring-loaded mouth gag, 20 mm custom-made plastic gag, 30 mm custom-made plastic gag and 42 mm common 1 inch needle cap. (B and C) A 20 mm custom-made plastic gag placed between maxillary and mandibular canines enables adequate mouth opening for performance of tooth extraction in the upper and lower jaw quadrants



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Figure 6 Assortment of friction-grip burs for use in a high-speed dental handpiece;



dental luxators have sharp, flat-tipped blades for penetrating and cutting the perio-dontal ligament between the tooth and alveo-lar bone. dental elevators have less sharp, more curved blades (Figure 8), fitting the cir-cumference of the tooth to exert a rotational force, thus tearing the periodontal ligament fibres. These instruments are grasped with the butt of the handle seated in the palm, and the index finger extended along the blade to act as a stop in case the instrument slips.9 Small root tip luxators, elevators and forceps are avail-able for removal of root remnants (Figure 9). The beaks of extraction forceps should not



round carbide burs (left), cross-cut fissure burs (middle) and round medium-coarse diamond burs (right). S = surgical (ie, the shank is longer than normal); L = long (ie, the working end is longer than normal)



Figure 8 Winged dental elevators (sizes 1–4, from left to right), the curved blades of which are designed to fit the circumference of a tooth



Figure 7 Feline tooth extraction kit. Root fragment elevators (A), winged luxating elevators (B), extraction forceps (C), root tip forceps (D), needle holder (E), suture scissors (F), curved Metzenbaum scissors (G), Adson thumb forceps (H), scalpel handle (I), surgical curette (J) and periosteal elevators (K)



Luxators and elevators are grasped with the butt of the handle seated in the palm, and the index finger extended along the blade to act as a stop in case of slippage.



fissure (to section multi-rooted teeth) and round diamond burs (to smooth alveolar bone) should be available (Figure 6). Numbers 3 (with metric ruler markings) and 5 scalpel handles accept numbers 10, 11, 15 and 15C blades.10 Adson 1 x 2 forceps provide a fine rat tooth grip, causing minimal trauma to delicate oral tissues. it is suggested that oral flaps are grasped on their connective tissue side rather than at their margins so as not to traumatize the latter prior to suturing. Sharp and narrow-tipped periosteal elevators (such as Glickman 24G or Periosteal EX-9) are used to raise oral flaps and should always be part of a feline tooth extraction kit (Figure 7). The flat or concave side of the blade is used against the bone and the convex side against the soft tissue, reducing the risk of tearing or puncturing the elevated soft tissue.9



Figure 9 Small root tip luxators and root tip elevators (‘teasers’) for removal of root remnants



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fully close but still fit the circumference of feline teeth, thus reducing the risk of tooth fracture when a tooth or crown–root segment is grasped as far apically as possible for its removal.11 Surgical curettes are used for removal of debris and granulation tissue from an alveolar socket after tooth extraction. Curved, bluntended Metzenbaum scissors with serrated blades are used for dissecting the connective tissue side of oral flaps and fine cutting of their edges prior to wound closure. Specific suture scissors or a designated pair of Mayo scissors should be reserved for cutting sutures.10 Halsey or deBakey needle holders with serrated jaws are used to lock onto curved needles by a ratchet mechanism. The authors prefer a size 5-0 synthetic, absorbable monofilament material with a swaged-on, taper-point round, non-cutting needle for suturing tooth extraction sites in cats (Figure 10). Square or surgeon’s knots should be followed by four more throws to ensure knot security.9 Chlorhexidine gluconate (0.12%) is used for rinsing the mouth prior to tooth extraction. The results of a study conducted on canine fibroblasts suggest that the least toxic solution for rinsing open wounds is lactated Ringer’s solution.9 Autogenous bone (cancellous bone and cortical bone chips) as well as allograftbased (demineralized bone of the same species) and ceramic-based (calcium phosphate, calcium sulfate and bioglass) bone graft substitutes are most commonly used in veterinary dentistry, although they are not routinely needed in extraction sites.12,13 Gauze swabs (size 3 x 3 inches, 7.5 x 7.5 cm) allow digital control of hemorrhage during tooth extraction procedures. Lavage with refrigerated lactated Ringer’s solution may also provide good hemostasis. Excessive bleeding from tooth extraction sites near tubular structures such as the mandibular and infraorbital canals can effectively be controlled by packing the alveo-lar sockets with a small amount of bone wax (a sterile beeswax-based compound).9



Figure 10 Size 5-0 synthetic, absorbable monofilament material with a swaged-on, taper-point round, non-cutting needle



R E V I E W / Oral anatomy and tooth extraction



Practical considerations If a tooth needs to be extracted in the area of previous radiation therapy, the procedure should be performed soon after the acute side effects have worn off (eg, after 6–8 weeks) rather than waiting months or years, as the potential for wound healing will not improve but become progressively worse.



Obtaining signed or witnessed verbal consent from the client about the number of teeth to be removed is important prior to performing any tooth extraction.



Tooth extraction techniques Closed extraction Closed extraction in the cat is primarily performed for maxillary and mandibular incisors, maxillary second premolars, maxillary first molars, and mobile teeth presenting with significant attachment loss. Employing a closed extraction technique for other teeth risks their fracture, which then warrants an open extraction technique in order to remove root remnants. The gingival attachment around the tooth is incised with a number 15 scalpel blade. A dental elevator with a curved blade that best fits the circumference of the tooth is selected. The instrument is inserted into the periodontal ligament space between the tooth and alveolar bone. Careful and steady rotation of its handle will create pressure on the tooth and causes the periodontal ligament to stretch and tear.3 (Note that performing a ‘wiggling’ motion has the potential to crush adjacent alveolar bone.) As the periodontal ligament space is widened, the dental elevator can be advanced apically and rotational pressure is repeated. The instrument should be inserted at other sites around the tooth until it is mobile enough for retrieval with an extraction forceps. The apex of the extracted tooth is inspected and palpated, ensuring no fracture has occurred. The extraction site is debrided with a surgical curette, and sharp bony edges are smoothed. The wound is rinsed and then sutured closed in a simple interrupted pattern.6,14 Sectioning of multi-rooted teeth provides two or more single-rooted crown–root segments that are extracted as if they were singlerooted teeth. Gentle reflection of the gingiva with a periosteal elevator will reveal the exact location of the furcation, decreasing the risk of damage to the gingiva during tooth sectioning. Sectioning is accomplished with a fissure bur, starting from the furcation and progressing through the crown.3 Two-rooted teeth are separated into two single-rooted crown–root segments. The three-rooted maxillary fourth premolar tooth is separated into three onerooted crown–root segments. in addition to vertical advancement of a dental elevator into the periodontal ligament space, the instrument can also be inserted horizontally in between the sectioned crown–root segments to lever them out of their alveoli.6,14



Closed extraction is primarily performed for maxillary and mandibular incisors, maxillary second premolars, maxillary first molars, and mobile teeth presenting with significant attachment loss.



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or two releasing incisions, extending from the gingival margin over the mucogingival junc-tion 3–7 mm (depending on flap location) into alveolar mucosa, are made and a full-thick-ness (mucoperiosteal) flap is raised. Smaller to midsized, round carbide burs attached to a watercooled dental handpiece are used to remove alveolar bone at the labial and buccal tooth surface by as much as one- to two-thirds of the length of each root.3 Septal bone does not have to be removed, except when approaching the mesiopalatal root of the maxillary fourth premolar. Narrow slots can be created at mesial and distal aspects of each root to allow for better elevator purchase.



Open extraction Feline teeth are quite delicate due to their small size and become even more brittle when affected by resorption. An open extraction technique is employed particularly when multiple teeth in one jaw quadrant require removal. other indications for open extraction include large and periodontally intact perma-nent teeth, unerupted teeth and – rather rare in the cat – firmly seated deciduous canine teeth. Extrac tion of maxillary and mandibular canine and cheek teeth in a cat is illustrated in Figures 11–23. The gingival attachment around the tooth is incised with a number 15 scalpel blade. one



Open extraction of left maxillary canine (204) and cheek teeth (206–209) in a cat



Figure 11 A vertical releasing incision is made into gingiva and alveolar mucosa at the mesial aspect of the canine tooth (A). A triangular oral flap is raised with a periosteal elevator (B and C); note the position of the infraorbital neurovascular bundle as it exits the infraorbital canal at the infraorbital foramen (arrow). Alveolectomy is performed with a round bur (D)



Figure 12 Narrow slots are created with a round carbide bur at mesial and distal aspects of each root (A). Multirooted teeth are sectioned with a cross-cut fissure bur (B). The mesiopalatal crown–root segment must be separated from the mesiobuccal crown–root segment of the fourth premolar tooth (C and D)



Continued on pages 907–910



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Open extraction is performed principally when multiple teeth in one jaw quadrant require removal, as well as for large and periodontally intact permanent teeth and unerupted teeth. Sectioning of multi-rooted teeth, extraction of crown–root segments, debridement and rinsing of the wound are performed as described for the closed extraction technique. Slight deflec-tion of lingually/palatally located gingiva allows for safe smoothing of alveolar bone and avoids iatrogenic injury to soft tissues.3,6,14



irregular or necrotic flap margins are trimmed with Metzenbaum scissors. The con-



nective tissue side of the flap is debrided with a surgical curette, ensuring removal of infect-ed and inflamed granulation tissue. Utilizing stay sutures or grasping a flap on its connec-tive tissue side with a thumb forceps will minimize iatrogenic trauma to the flap mar-gin. The periosteum at the base of the flap is incised in a distomesial direction, allowing the flap to become mobile.15 The back of a scalpel blade can be used to ‘strum’ and weaken the periosteal layer, followed by blunt dissection with scissors. A small stab incision might also be made in the periosteum through which the blade tips of closed scissors are inserted and opened to undermine the periosteal layer. The wound is rinsed and the flap sutured to the palatal/lingual gingiva in a simple interrupt-ed pattern.3,16,17



Continued from page 906



Figure 13 A dental elevator is inserted into the periodontal ligament space between the canine tooth and alveolar bone, and rotated to stretch and tear the periodontal ligament (A and B). Once the tooth is mobile enough, it is grasped as far apically as possible with an extraction forceps and removed (C and D)



Figure 14 Fracture of the mesial crown–root



segment of the third premolar has



occurred (A). Additional alveolar



bone around the root remnant is removed with a round carbide bur (B). A special root tip elevator is used to elevate and retrieve the root remnant (C and D)



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Continued from pages 906–907 Figure 15 The mesiopalatal crown-root segment of the fourth premolar is still in place (A). The septal bone separating the already extracted mesiobuccal crown–root segment from the mesiopalatal crown–root segment is reduced with a round carbide bur (B). The mesiopalatal crown–root segment is elevated and removed (C and D)



Figure 16 The first molar tooth is extracted (A). The gingiva on the palatal aspect is elevated (B). Sharp bony edges are smoothed with a round mediumcoarse diamond bur (C), and the alveolar sockets are debrided with a surgical curette (D)



Figure 17 Irregular wound margins are trimmed with tissue scissors (A). The periosteum at the base of the flap is incised with a blade (B) and bluntly dissected with tissue scissors (C). The flap is sutured to the palatal gingiva in a simple interrupted pattern (D)



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Continued from pages 906–908



Figure 18 Dental radiographs obtained before (A) and after (B) tooth extraction. The extracted teeth are lined up (C)



Figure 19 A vertical releasing incision is made into gingiva and alveolar mucosa at the mesial aspect of the canine tooth (A). A triangular oral flap is raised with a periosteal elevator (B and C); note the position of the middle mental neurovascular bundle as it exits the mandibular canal at the middle mental foramen (arrow). Alveolectomy is performed with a round bur (D)



Figure 20 Narrow slots have been created with a round bur at mesial and distal aspects of each root (A). Multirooted teeth are sectioned with a cross-cut fissure bur; note that the furcation of the first molar is distal to the middle of its M-shaped crown (B). The canine tooth is elevated and removed (C and D)



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Continued from pages 906–909



Figure 21 The sectioned crown–root segments of the first molar are elevated and removed (A–C). The gingiva on the lingual aspect is elevated (D)



Figure 22 The gingiva on the lingual aspect is elevated up to the empty alveolus of the extracted canine tooth to facilitate suture placement (A). Sharp bony edges are smoothed with a round mediumcoarse diamond bur (B). Irregular wound margins are trimmed with tissue scissors (C). The flap is sutured to the lingual gingiva in a simple interrupted pattern (D)



Figure 23 Dental radiographs obtained before (A) and after (B) tooth extraction. The extracted teeth are lined up (C)



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Extraction of root remnants Root remnants under healthy gingiva and embedded within normal bone (eg, no periapical pathology) may be left where they are. in cats, they often appear clinically as a small gingival bulge in the area of a missing tooth. Retained roots that ‘poke’ through the gingiva, root remnants with sinus tracts, roots fractured during the extraction procedure, and roots remaining after mandibulectomies and maxillectomies must be removed to prevent infection and inflammation of the bone.3,18,19 The temptation to utilize a bur in a dental handpiece to ‘pulverize’ or ‘drill out’ a retained root must be resisted. Complications associated with this amateurish technique include incomplete removal of dental tissue, alveolar bone damage, injury to inferior alveolar and infraorbital neurovascular bundles, transportation of root tissue into the mandibular canal, infraorbital canal or nasal cavity, and subcutaneous and sublingual emphysema and air embolus.6



Special root tip elevators and root tip forceps are available for removal of small root remnants. if removal in a closed fashion is not possible, a mucoperiosteal flap and partial alveolectomy should be performed to facili-tate complete tooth extraction.20 if the tooth fractures during open extraction, additional alveolar bone (if necessary, the entire alveolar bone labial or buccal to the root remnant) is removed so that the root remnant can safely be retrieved. An endodontic file can be thread-ed into the root canal of a root remnant to help retrieve it. 21 Retrieval of root remnants from the mandibular canal, infraorbital canal or nasal cavity after accidental repulsion into these spaces must be carefully planned to avoid significant hemorrhage.3



Figure 24 Clinical photographs showing crown amputation of the left maxillary canine tooth (204) with intentional retention of resorbing root tissue in a cat. A mucoperiosteal flap is raised (A). The crown is amputated with a cross-cut fissure bur at the level of the cervical portion of the tooth (B). The resorbing root is reduced with a round medium-coarse diamond bur to about 1–2 mm below the level of the alveolar margin (C). The gingiva is sutured closed over the wound (D)



Root remnants under healthy gingiva and embedde d within



Crown amputation Many teeth in cats undergo dentoalveolar ankylosis and root replacement resorption. Such teeth have lost their periodontal liga-ment space and the roots are fused to alveolar bone. Therefore, in the absence of tooth mobil-



normal bone may be left where they are.



ity, periodontitis, endodontic disease, peri-apical pathology and stomatitis, teeth with dentoalveolar ankylosis and root replacement resorption can be managed by crown amputation with intentional retention of resorbing root tissue. This procedure should only be employed when closed or open extraction cannot be accomplished on teeth with radio-graphic confirmation of dentoalveolar ankylo-sis and root replacement resorption.3



The procedure begins by incising the gingival attachment around the tooth. A mucoperiosteal flap with or without releasing incisions is made. The crown is severed from the remainder of the tooth with a round or fissure bur attached to a high-speed handpiece. The resorbing root is further reduced with a round diamond bur to about 1–2 mm below the level of the alveolar margin (Figures 24 and 25). This allows a blood clot to form over the remaining root tissue into which alveolar bone can grow during healing. The flap is sutured over the wound, and postoperative radiographs are obtained.3,22



Postoperative management Pain control and wound care are accomplished with analgesic medications and antiseptic oral gels. Cats seem to tolerate the taste of zinc ascorbate gel better



Figure 25 (A) Preoperative radiograph of the left maxillary canine tooth from Figure 24, showing root replacement resorption (asterisk). (B) Postoperative radiograph following crown amputation, showing reduction of the resorbing root to about 1–2 mm below the level of the alveolar margin (double-ended arrows)



than that of chlorhexidine gluconate products.3 Soft food should be given for 2 weeks. Cats with stomatitis undergoing partial or full-mouth tooth extraction may benefit from placement of an oesophagostomy feeding tube.23



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force. it is more likely in the presence of severe periodontitis or other pathology that has weakened the jaw bone. When occurring near the mandibular canine,27 the fracture often is non-displaced, and creating two intraosseous sutures may be sufficient for healing.



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Avoidance and management of complications The entire tooth must be removed in order to avoid complications such as local or systemic infection.18,19



 Oronasal fistula oronasal communication



 Retained root remnants if a root remnant



cannot be retrieved, a note is made in the dental record and the client informed about the complication. The surgical site should be evaluated periodically by means of clinical and radiographic follow-up examinations.11   Hemorrhage Bleeding can usually be controlled by means of digital pressure with a gauze swab. Severe bleeding is rare and likely due to injury of vessels in the mandibular or infraorbital canal or the mucosa of the nasal cavity. Packing a small amount of bone wax into an alveolus is usually sufficient to stop excessive bleeding.3   Iatrogenic trauma Repeated brief



‘wiggling’ motions during tooth extraction will crush and soften adjacent alveolar bone, making elevation of a tooth more difficult. Excessive leverage against adjacent teeth should be avoided to prevent their elevation or fracture. developing permanent teeth could be injured when extracting adjacent deciduous teeth.3 instrument slippage could cause local or distant soft tissue trauma or injury to the operator or assistant.24–26   Sublingual edema iatrogenic trauma or excessive pharyngeal packing can result in sublingual edema. intravenous dexamethasone may be administered if respiratory compromise is present.



Repeated ‘wiggling’ motions during tooth extraction will crush and soften adjacent alveolar bone, making elevation of a tooth more difficult.



 Sublingual sialocele injury to salivary ducts in sublingual tissues occasionally causes a sublingual sialocele (ranula), which is treated by marsupialization or resection of 3 the  sublingual and mandibular glands.   Mandibular fracture Mandibular fracture is usually due to insufficient preparation prior to extraction (eg, important pathology remaining undetected because radiographs were not obtained) or the use of excessive



in the area of a missing maxillary canine tooth is rare in the cat. An acute oronasal fistula may be encountered during extraction of maxillary teeth and is managed by suturing a flap over the extraction site.3   Bite trauma After extraction of a maxillary canine tooth, the tight upper lip may position more palatally, allowing the ispilateral mandibular canine tooth to bite into it. Reducing the pointed tip of the mandibular canine by 1 mm (be careful about pulp exposure!) is usually sufficient to solve the problem; exposed dentin should be treated with a layer of unfilled resin (dental adhesive) to reduce postoperative sensitivity.   Emphysema Emphysema sometimes occurs after tooth sectioning or alveolectomy with air-driven high-speed equipment. This usually resolves spontaneously within days. Air must never be blown into alveolar sockets or onto bleeding surfaces, as it can cause air emboli.3,28   Wound breakdown Wound dehiscence is primarily caused by tension on suture lines. The wound can be resutured or is left to granulate and epithelialize. A blood clot remaining in the alveolus, regardless of whether or not the extraction site is sutured closed, will avoid local infection and inflammation such as alveolar osteitis (‘dry socket’).  Non-healing extraction site if an



extraction site is not healing, a biopsy is warranted to rule out neoplasia.  Note that temporary bacteremia during and after tooth extraction procedures is not an indication for the perioperative use of systemic antibiotics in an otherwise healthy patient.3



KEY POINTS      



 The veterinarian should be familiar with the tissues that hold the teeth in the jaws.  The client must consent to the number of teeth to be removed prior to the procedure being performed.  Proper instrument handling is paramount in avoiding iatrogenic injury.   Feline teeth are quite delicate and become brittle when affected by resorption.  The entire tooth must be removed in order to avoid local or systemic infection.   Tension is the most common reason for flap dehiscence.  Roots remaining in the jaws must be recorded in the patient’s medical record.



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R E V I E W / Oral anatomy and tooth extraction



Funding The authors received no specific grant from any funding agency in the public, commercial or notfor-profit sectors for the preparation of this article.



Conflict of interest The authors do not have any potential conflicts of interest to declare.



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