Iatrogenic tooth damage

35 Iatrogenic tooth damage




INITIAL PRESENTATION


Swelling of the left rostral mandible and a draining fistula at the ventral border of the left rostral mandible.



PATIENT DETAILS


A 6-year-old, neutered male, Labrador retriever.



CASE HISTORY


A rostral mandibular fracture was repaired 5 years earlier, when the dog was a year old, at a specialist centre with orthopaedic expertise. The clinical notes and radiographs had been ‘lost’, so the details of the treatment were not available to us.


A fistula at the ventral border of the left mandible developed 3 years after the mandibular fracture repair. The dog was then referred back to the same specialist centre. Radiographs were taken, which showed a periapical lucency associated with 304 and a diagnosis of ‘apical abscess’ was made. The condition was treated with a long course of antibiotics. The problem resolved but flared up again within 3 months of ceasing antibiotic treatment. The dog was then treated intermittently with antibiotics for just over 2 years before being referred to us. Antibiotic therapy resulted in an improvement, but the fistula remained and started to drain within a few weeks of stopping an antibiotic course.



ORAL EXAMINATION – CONSCIOUS


The dog was extremely well behaved, and allowed careful conscious examination of the head and mouth, which revealed the following:


1. Occlusion normal

2. Generalized gingivitis

3. All mandibular incisors were missing

4. Some mandibular premolars were missing

5. Hard swelling of the rostral left mandible (no reaction to firm palpation)

6. Draining fistula at the ventral border of the left mandible (thick, yellow fluid).


ORAL EXAMINATION – UNDER GENERAL ANAESTHETIC


A thorough oral examination, including investigating periodontal parameters, was performed and all findings were noted on the dental record.


In summary, examination under general anaesthesia identified the following:


1. Mild generalized gingivitis

2. Hard swelling of the rostral left mandible (Fig. 35.1)

3. Draining fistula at the ventral border of the left mandible (Fig. 35.1)

4. All mandibular incisors, as well as 307, 308, 406 and 408, missing

5. Gingival inflammation at the region of the missing 406.

image

Figure 35.1 Oblique ventrolateral photograph of the left mandible. The ventral border of the left mandible is hard and swollen with a drainage tract. The drainage tract originated from the periapical inflammation of 304.



FURTHER INVESTIGATIONS


Radiographs were taken of the rostral mandible, 304 and 404, and at the sites of the missing 307, 308, 406 and 408.



RADIOGRAPHIC FINDINGS


The following were evident on the radiographs:


1. Bony swelling with periosteal new bone on the left rostral mandible

2. Teeth 304 and 404 were immature teeth with wide pulp system diameter and incomplete apical closure (Fig. 35.2a–c)

3. Lucency around the apex of 304 (Fig. 35.2a)

4. Circular lucencies at the midroot of both 304 (Fig. 35.2a, c) and 404 (Fig. 35.2a, b)

5. Root remnants of 307 (Fig. 35.2c) and 406 (Fig. 35.2b)

6. Teeth 308 and 408 absent

7. All mandibular incisors absent.

image

Figure 35.2 Radiographs of the rostral mandible.


(a) Rostrocaudal view. Although the dog is 6 years old, 304 and 404 are immature teeth (wide pulp system diameter and incomplete apical closure). The development of these teeth is compatible with a dog younger than a year of age. Consequently, pulpal inflammation and necrosis (which stops further tooth development) must have occurred at around 9 months of age. Note the circular lucencies at the midroot of both 304 and 404. These are compatible with drill holes for a pin or a screw to repair the rostral mandibular fracture. The pulpal inflammation and necrosis of 304 have spread to involve the periapical tissue, as evidenced radiographically by the radiolucent zone around the apex of the root. The periosteal new bone formation on the left is a consequence of the pulp and periapical disease of 304.

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Sep 3, 2016 | Posted by in SMALL ANIMAL | Comments Off on Iatrogenic tooth damage
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