2 Jan Bellows All Pets Dental, Weston, FL, USA Oral and dental pathology is a common finding in companion animals. In many cases, when detected by the owner, the disease will be well advanced and obvious at presentation, while others are more obscure, requiring further diagnostics. Signs and symptoms may indicate oral disease to be primary or secondary in nature [1]. A thorough examination in coordination with a suitable knowledge of anatomy and function is the basis for diagnostic ability. Proper examination and accurate diagnosis is the first step to appropriate treatment and preventative care planning. Clinically, oral diagnosis is a seven‐part interactive process of history, whole body physical examination, facial exam, initial oral survey, pre‐anesthesia diagnostic testing, in‐depth oral examination, and oral diagnostic testing [2]. The gathering of history is the foundation of a proper care. It relies on the owner’s direct personal involvement and provides information that can be an invaluable aid in directing the full examination. In addition, the history is the link between all other parts of the physical, oral, and laboratory examination. A complete history should provide vaccination status, details of diet, appetite, water consumption, levels of professional and home dental care, past disease problems and treatments, current problems and treatments in progress, exposure to infectious diseases, traumatic incidents, and behavioral changes, all of which may help the clinician fully evaluate every aspect of the animal’s general health. Signalment of age, breed, and sex is always the starting point. History encompasses past and present information concerning the individual, family line, other household pets, and breed characteristics. Additionally, medications previously and currently being taken should be recorded, both for general information and avoiding adverse reaction problems [3–5]. Once significant general data are obtained, information more specific to oral and dental pathology should be closely scrutinized. Information of actual oral symptoms should include onset, duration, degree of severity, and recurrence profile [6]. Details of type of diet, water additives, chew toys, and eating habits should be scrutinized. Additionally, history of chronic cough, regurgitation, vomiting, and skin allergies yield important information in that those conditions produce effects on the oral cavity. Questions with respect to the patient’s hesitancy to pick up, chew, or swallow food can provide significant information. Has the animal been observed to drop food, toys, or training articles from the mouth? Has quivering of the jaw or chattering of the teeth been noticed, especially while training articles are in the mouth? What are the training articles and of what are they made? Sensitive teeth more commonly react to metals, from both thermal and galvanic stimulus. Food shifted to or chewed primarily on one side or a preference for soft food may be a sign of periodontal or endodontic disease. Hesitancy in swallowing food can be due to oral inflammations, neoplasia, ulcers, sensitive teeth, tonsillitis, and foreign bodies. Inappetence and anorexia are associated with general disease processes, as well as signs of oral ulceration, inflammation, and pulp exposure within the oral cavity [6]. True anorexia is uncommon in oral disease, except in cases of severe pain. In such cases, systemic disease should first be ruled out. Oral pain can additionally result in pawing at, tilting, bobbing, shaking, and sliding of the head and mouth along the floor. Differential diagnosis of these signs include pathology of the skin, lips, ears, eyes, salivary glands, and central nervous system. One of the most commonly reported signs of oral disease is simply bad breath or halitosis. This condition is reported more frequently in house pets, probably due to their close contact with owners. Periodontal disease is the most common cause of halitosis [7], which occurs due to the bacterial breakdown of food and other materials in gingival pockets. Other causes of oral malodor are stomatitis, tumors, cleft palates, cleft lips, oronasal and oroantral fistulas, and foreign bodies. Differential diagnosis should include uremia, sinusitis, gastrointestinal problems, respiratory diseases, nasal disorders, diet, lip fold pyoderma, and lesions caused by licking or chewing abscesses or infected anal glands. Clicking or popping noises noticed during jaw movement is typically associated with problems with the temporomandibular joint (TMJ), or the coronoid process and zygomatic arch [8–10]. Differential diagnoses can be dental, jaw, or palatal fractures. Acute or chronic oral pain associated with mandibular movement or open mouth behavior can be related to numerous oral problems. Differential diagnoses include dental, jaw or palatal fractures, myositis, foreign bodies, mandibular neuropraxia, salivary gland disease, craniomandibular osteopathy, severe stomatitis, acute necrotizing ulcerative gingivitis (ANUG), contact mucositis (chronic ulcerative paradental stomatitis (CUPS)) or kissing ulcers, tumors, TMJ disease, or coronoid process problems with the zygomatic arch [6 8–10]. Chronic ptyalism or drooling is most commonly caused by a reluctance or inability to swallow rather than increased salivary flow or production [6]. Acute endodontic exposure, severe inflammatory disease or ulceration of any of the oral mucosae, and foreign bodies are more common oral causes. Other causes can be systemic bacterial infections such as leptospirosis and viral diseases such as rabies and the feline upper respiratory infections. Toxins can also result in acute excessive salivation; examples are man‐made organophosphates and animal toxins from the toad Bufo marinus. Heat and excitement can also result in ptyalism, but this is generally acute in onset without other obvious symptoms. Facial swellings, edema, draining tracts, or bleeding from the mouth, nose, or facial area can have oral origins. Endodontic, periodontal, salivary disease, or trauma can result in these symptoms. Differential problems are insect and snake bites, allergic reactions, tumors, hematomas, and subcutaneous air [2, 6]. The external physical examination should never be overlooked in the attempt to press on to more obvious oral problems. Flea and skin allergies may lead to hair chewing, resulting in attrition of the incisors with loose hair tangled around teeth, acting to retain debris and to enhance an environment for periodontitis [2]. Excessive panting is often noticed in small breed dogs due to sublingual granulomas (gum chewing lesions). Auscult the heart and lungs for soundness as these are the most common areas to result in complicating factors associated with sedation or anesthesia used in the in‐depth oral exam, dental scaling, and oral treatments [2]. Closely observe the face, mandible, and head for swellings that can indicate neoplastic enlargements, cellulitis, or abscesses [2, 7 11–16]. Cellulitis and abscessation can be due to foreign bodies, fight wounds, periodontal disease, or endodontic disorders (Figure 2.1). Fistulous tracts may be present with or without serous or purulent drainage according to the cycle of disease. Neoplasia and eosinophilic granuloma complexes may result in raised ulcerative lesions of the lip, gingiva, or enlargement of the mandibular lymph nodes [6]. Always palpate the lymph nodes and salivary glands in the head and neck region for enlargement or indications of pain. Figure 2.1 Swelling beneath the right eye secondary to endodontic disease. Asymmetry of the face or head can be seen in hereditary or congenital abnormalities, inflammatory disease, neoplasia, dislocations, fractures, and nerve damage (Figure 2.2). Some of the more common of these in the cat are dislocation of the TMJ and maxillary or mandibular fractures and in the dog allergic responses and mandibular/maxillary asymmetry [8, 9]. Open mouth disorders are usually a result of trauma to the joint (TMJ), maxillary or mandibular bones (fractures), or nerve damage or disease [8–10]. Figure 2.2 Decreased right‐sided temporal muscle mass secondary to masticatory myositis. The initial oral survey is generally performed in the exam room following the physical examination, but normally without the aid of sedation or anesthesia (Figure 2.3). Correct assessment of an animal’s oral and dental health relies on familiarity with normal anatomy. The amount of information that can be obtained varies greatly from individual to individual based upon the animal’s temperament and the owner’s ability to properly and adequately restrain the pet. A well‐trained technician can many times facilitate this process better than the owner, although they will typically need to be present to elaborate on the primary complaint. A detailed systematic approach is necessary for a complete oral examination [17, 18]. Head type and symmetry, swellings, draining lesions, and occlusal evaluation is always the beginning point of the oral examination. Figure 2.3 Examination of the lips and face. Start with the lips and commissures. Examine for masses, pyoderma, or tumors. Lift the lips with the thumb and forefinger and examine the exposed teeth and mucosae. Note malocclusions (mandibular mesioclusion, mandibular distoclusion, mandibular and maxillary asymmetry) and then progress to an open mouth examination if the patient safely allows. There are several ways to adequately open and examine the mouth. The most common is an overhand technique with the palm over the bridge of the nose and the thumb behind the canine tooth on one side and the index finger behind the canine tooth on the opposite side. The opposite hand grasps the mandible from below with the forefinger and thumb to either side and the index finger placed on the incisors and used to leverage the mouth open. Care should be exerted in trauma and severe periodontal cases as theses jaws can be easily fractured. Evaluate the mucous membranes for color, perfusion time, petechia, moistness, ulcerations, lacerations, or swellings. Examine the gingivae for color, inflammation, hyperplasia, recession, sulcal exudate, clinical sulcal bleeding, normal architecture, and the presence of swellings or tumors. Inspect the teeth for malposition fractures, discoloration, calculus, plaque, mobility, caries, cervical line lesions, and developmental defects. The buccal surfaces can generally be examined on the alert pet and the lingual surfaces under sedation. The roof of the mouth should be examined for swellings, defects, foreign bodies, rugae symmetry or loss of rugae. The tongue should be mobile and with good strength. Inspection of the ventral tongue can be facilitated by pushing a finger up into the ventral intermandibular space [6]. Always check under the tongue for tumors, lacerations, ulcerations, and foreign bodies. The salivary papillae should be free of inflammation and patent. Patency can sometimes be difficult to assess without passing a catheter, but in some cases by placing light pressure caudal to the papilla and rolling the finger towards the duct, saliva may be expressed. Observe also for halitosis, oral bleeding, epistaxis, rhinitis, and the condition and strength of the masticatory muscles. Test strips detect changes in gingival health that cannot be seen by visual inspection without anesthetizing the patient. The strips measure the concentration of thiols generated by anaerobic bacteria associated with periodontal disease. Studies have shown that when periodontal health declines, anaerobic bacteria proliferate as periodontal pocket depth increases. The concentration of thiols in gingival crevicular fluid (GCF) increases as periodontal disease increases. The test strip is rubbed along the gingival margin to collect an oral fluid sample on to a pad located on the end of the strip (Figure 2.4). Once removed, within 10 seconds, the pad will change color if elevated thiol levels are present. The result is compared to a color chart to determine the concentration of thiols, indicating disease activity. Figure 2.4 The test strip is rubbed along the gingival margin to collect an oral fluid sample on a pad located on the end of the strip. The pre‐anesthesia diagnostic testing is performed in order to reduce the risk of pathological and physiological complications during or following induction [2, 6]. Testing emphasis should be directed by the history, physical examination, and the initial oral survey. Tests are based upon the clinician’s assessment of the individual. In questionable cases, consultation with a board‐certified specialist in internal medicine and or anesthesia is recommended. Once available information has been correlated, the in‐depth oral examination can begin. A complete in‐depth oral examination can only properly be performed on an intubated patient under general anesthesia (Figure 2.5). All information discussed within the initial oral survey that was not obtained in full detail should be acquired at this time. This should incorporate the oral examination, periodontal examination, dental examination, and the charting process [19]. Figure 2.5 General anesthesia is necessary to be able to perform a complete dental examination. Periodontal disease is initiated when the bacteria in the mouth collects with a matrix of salivary glycoproteins and extracellular polysaccharides to form plaque that adheres to the tooth surface [11]. After a period of time, the plaque will mineralize to form calculus [7 11–13]. As the plaque contacts the attached gingiva, the bacteria and byproducts, joined later by the body’s own immune response, can cause inflammation, infection, and eventually destruction of tissues [20, 21]. At first, the supragingival plaque bacteria are Gram positive, non‐motile, aerobic cocci, but as the infection progresses deeper into the sulcus, Gram negative, motile, anaerobic rods predominate. The signs of periodontal disease include edema and inflammation of the gingiva, plaque and calculus deposition, halitosis, gingival bleeding when probed, ulceration, gingival recession, bone loss, mobile teeth, and tooth loss [22, 23]. The gingival sulcus is a groove or space between the gingival margin and the tooth and can be up to 1–3 mm in depth in the normal dog. The gingival margin of a cat is usually so closely associated with the tooth that any sulcus deeper than 0.5 mm may be considered abnormal [24]. The gingival sulcus should be examined with a periodontal probe for abnormal pocket depths and with an explorer for indications of tooth resorption, subgingival plaque, and calculus (Figure 2.6). The sulcus depth should be checked at four to six sites around the tooth, and variations from normal recorded on the animal’s chart (see Section 2.3 on Charting). Limited direct observation in the sulcus can be obtained by using a three‐way air water syringe. The air can be used to gently blow the sulcus open to look inside. Additionally, thin pieces of calculus may appear as chalky white areas when the air is blown across them. Figure 2.6 Explorer used to identify tooth resorption. The furcation is the site where two roots separate from the body of the tooth. In multirooted teeth, furcations are common areas of attachment loss and periodontal disease occurrence. Exposure of furcations and degree of exposure should be recorded (see Chapter 5 – Periodontology). Endodontic disease, although not as common as periodontal disease, is common in the dog and cat [14]. While some manifestations are significant indications of pulpal pathology, other endodontically compromised teeth are less obvious in their symptoms. A complete endodontic examination includes visual inspection and radiographic assessment. This assists in the diagnosis of the lesion and its localization to the area of origin [25, 26]. As in all veterinary cases, a thorough medical and dental history is needed to assess both the localized problem and the overall health of the patient. Specifically, any previous indication of oral discomfort, possible dental abscessation or facial trauma may warrant further investigation. The most obvious sign of endodontic pathology seen by the owner or the veterinarian will be a fractured tooth, whether just a crack or split, or up to partial loss of the crown with exposed canal. If the fracture is recent, the exposed pulp may appear pink or edematous, or hemorrhage may be present. These teeth can be painful, so palpation should be attempted with care. Once the pulp has necrosed and the nerve has died, the tooth should not be acutely sensitive, and a dark spot will indicate the canal opening. Teeth that have sustained enough trauma to disrupt the apical blood supply or cause irreversible pulpitis appear intact but discolored as the inflammatory byproducts leach into the dentinal tubules. An injured tooth that initially appears pink will turn purple to gray or beige later. As the pathology of the infection progresses, various indications of abscessation may become apparent. Mucosal swelling or discoloration, facial swelling, and fistulous tracts may appear, depending on the site of the problem. Palpating the defect with an endodontic explorer or pathfinder is sometimes possible in the awake patient, but full assessment will require general anesthesia. Checking for mobility of teeth fragments and the tooth proper, as well as gently spreading the cracks to see if they extend vertically, are helpful palpation practices that dictate therapy options. Placing a cold material in contact with various teeth to elicit an exaggerated response is one further test, but is most reliable in a calm, awake patient or one mildly sedated. Water or gelatin from a freezer bag can be frozen in a tuberculin syringe with the tip cut off to make a cold tester.
Oral Examination and Diagnosis
2.1 Introduction
2.2 Oral Diagnosis
2.2.1 History
2.2.2 General Physical Examination
2.2.2.1 Facial Exam
2.2.3 Initial Oral Survey
2.2.3.1 Periodontal Disease Test Strips/Thio Levels
2.2.4 Pre‐anesthesia Diagnostic Testing
2.2.5 In‐depth Oral Examination and Charting
2.2.5.1 Periodontal Disease
2.2.5.2 Endodontic Disease
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