Exam 1 Flashcards
Lecture 1
Tooth Anatomy
What type of teeth anatomy do dogs, cats, primates, humans have?
Brachydont: tooth with shorter anatomical crowns than root(s) at maturity
-Having short crowns
-Well developed roots
-Only narrow canals in the roots
**Hypsodont: tooth with long anatomical crown at tooth maturity, continuously erupting as occlusal wear takes place (e.g., horses and ruminants).
Name all the parts of the tooth
- Enamel
- Dentin
- Pulp
- Cementoenamel Junction (neck
- Gingiva
- Periodontal Ligament
- Cementum
- Alveolar Bone
- Apex
- Cusp
What is the Cusp?
A pronounced point on the occlusal or most coronal portion of a tooth.
Describe the enamel and Dentin
What cells produce enamel and dentin?
What is the thickness of enamel in cats and dogs?
Enamel
-highly mineralized inorganic hard tissue that covers the dentin of the crown,
-produced by AMEOBLASTS.
-Amelogenesis: stops prior to tooth eruption. It can’t be rapider once it stops growing. Heat/cold sensitivity when damaged.
Dog: <0.1 to 0.3mm
Cat: <0.1mm
Dentin
-Hard tissue covered by enamel (crown) and cementum (root)
-Produced by ODONTOBLASTS throughout the life of the tooth.
-Dentin is porous
-Primary dentin: produced during development of the tooth
-Secondary dentin: produced throughout life of a vital tooth, causing the pulp cavity to become progressively narrower.
-Tertiary dentin: reparative dentin produced in response to injury and irritation
DENTINAL TUBULES: contain cytoplasmic extensions of odontoblasts. Each tubules contain fluid, and come contain nerve extending from the pulp.
-Tooth pain results from fluid shifts and nerve stimulation due to changes in temperature, desiccation, or osmotic changes (e.g., foods with high sugar content) in the area of exposed tubules.
Periodontium Components
- Gingiva
- Periodontal Ligament
- Cementum
- Alveolar bone
These structures are affected by, and ultimately lost from periodontal disease
Describe Cementum and Periodontal ligament
Cementum
-Hard tissue that covers the root and is produced by CEMENTOBLASTS at apex of root
-Periodontal ligament and gingiva attach to cementum
-Width increases with age
-Hepercementosis: occurs from chronic irritation and “lock” the tooth into the alveolar socket.
-Loss of cementum prevents reattachment of periodontal ligament.
SHARPEY’S FIBERS (cementum)
-Embedded in cementum and transverse the periodontal space to anchor the tooth in alveolar bone.
Periodontal Ligament
-Shock absorption, transmits occlusal forces, attaches to bone, supplies nutrients, provides tactile and proprioceptive information
-SHARPEY’s FIBERS: travel transversely in the coronal portion of the tooth and more oblique toward the apex.
-Radiographically the PDL appears as a dark line surrounding the root.
Describe the Pulp
-Soft tissue, connective tissue containing nerves, blood, and odontoblasts, which produce dentin.
-Pulp proper: layer containing major vessels, nerves, and connective tissue. Sharp localized pain, myelinated A-delta fibers, Dull pain unmyelinated C fibers.
What is the gingival sulcus?
What is the normal sulcus depth?
The gingiva is keratinized and consists of four layers: Stratum corner, stratum granulosum, stratum spinous (prickle cell layer) and stratum basale.
Gingival sulcus: space between the tooth surface and gingiva.
Normal sulcus depth = DOGS: <3mm CATS: <1mm
Positional Terminology
-Mesial: inter proximal surface of the tooth that faces rostrally or towards the midline of the dental arch.
-Distal: inter proximal surface that faces caudally or away from midline of the dental arch.
-Vestibular: surface of the tooth facing the lips “buccal” and “labial” are acceptable alternatives
-Lingual: refers to the surfaces of the MANDIBULAR teeth that face the tongue:
-Palatal: refers to the surface of the MAXILLARY teeth that face the palate
-Rostral: referring to a location toward the tip of the nose
-Caudal: referring to a location towards the tail
-Ventral: referring to a location towards the lower jaw
-Dorsal: referring towards the top pf the head or muzzle
-Occlusal: refers to the surface of the tooth that faces the tooth of the opposing arcade
-Proximal: referring to the medial and distal surfaces of a tooth that come in close contact to an adjacent tooth
-Interproximal: referring to the space between adjacent teeth.
-Coronal: referring to a location or direction toward the crown of the tooth.
-Subgingival: referring to a structure or area that is apical to the gingival margin
-Supragingival: referring to a structure or area that is coronal to the gingival margin
Modified Triadan Tooth Numbering System CANINE
Permanent
2[I 3/3, C 1/1, PM 4/4, M 2/3] = 42 teeth
Right upper quadrant: 100 (500 when referring to deciduous teeth)
Left upper quadrant: 200 or 600 deciduous
Lower right quadrant: 400 or 800 deciduous
Lower left quadrant: 300 or 700 deciduous
Mesial to distal: 01 to 10 on maxilla
Mesial to distal: 01 to 11 on mandibule
Canine: 04
PM1: 05
M1: 09
M3: 11 mandible only
Which teeth are 1 rooted teeth?
Incisors and canine teeth mandibular and maxillary
-01 to 04
-Plus PM1 (05)
Mandibular
-M3 (11)
Which teeth are two rooted teeth?
Maxillary
-PM2 (06)
-PM3 (07)
Mandibular
-PM2 (06), PM3 (07), PM4(08), M1 (09), M2 (10).
Which teeth are three-rooted?
Maxillary
-PM4 (08)
-M1 (09)
-M2 (10)
Canine Tooth Eruption Schedule
(don’t have to memorize)
Deciduous teeth
2[ I 3/3, C 1/1, PM 3/3] = 28 teeth
Normal Occlusion - Dog
What teeth superimpose normally?
Mandibular M1 with Maxillary PM4
Feline Teeth
Dental formula - Modified Triadan System
Permanent teeth
2[ I 3/3, C 1/1, PM 3/2, M 1/1] = 30
I: 101-103 (Right upper) 201-203 (Left upper) 301-303 (Left lower) 401-403 (Right lower)
C: 104, 204, 304, 404
PM: NO 05 Maxillary
PM: 06-08
M: 09
PM: NO 05, 06 Mandibular
PM: 107-108
M: 09
Which teeth are one, two, and three-rooted? Feline
One rooted
Maxillary
I: 01-03
C: 04
PM: 06 (no 05 remember?)
Mandibular
I: 01-03
C: 04
Two Rooted
Maxillary
PM: 07
M: 09
Mandibular
PM: 07-08
Three rooted
Maxillary
PM: 08
Mandibular
No three-rooted
Which are the strategic canine teeth?
Which are more commonly taken out?
Canines
-Large, well developed roots
-Important to maintain the integrity of the mouth and to chew hard food
Carnassial teeth
-PM4 maxillary (08)
-M1 mandibular (09)
Lecture 2
Name the anatomical structures
- Parotid salivary gland
- Parotid duct: drains at level of the maxillary 4th premolar = build up
- Mandibular salivary gland
- Mandibular lymph nodes
Clinical importance
Avoid transecting ducts during oral surgery/surgical extraction of maxillary PM4 (08) and M1 (09)
Zygomatic salivary gland ducts open near maxillary M1(09) and M2 (10)
Mandibular salivary duct opens on the sublingual caruncle
Lingual Molar Salivary Gland in Cats
What can it be confused with?
Avoid when?
Lingual molar salivary gland near mandibular M1 (09)
Confused for an abnormal structure
Avoid during surgical extraction of mandibular M1
What are significant skeletal landmarks and used for what procedures?
Caudal Maxillary Nerve Block
Ventrodorsal view of caudal palate
-M2 (10)
-Maxillary tuberosity
Caudodorsal view of orbit
-Zygomatic process of frontal bone
-Maxillary foramen (leads to infraorbital canal)
-Maxillary tuberosity
-M2 (10)
Sites of nerve blocks
Inferior Alveolar Nerve Block
-Infraorbital foramen
-Middle mental foramen
-Mandibular Canal: location of major blood/nerve supply during surgical extraction of mandibular teeth
Be able to recognize normal radiolucency on radiographs
-Mandibular foramen site of the inferior alveolar nerve block
Palatine fissure
-Recognize maxilla on radiographs
Mandibular symphysis
-Fibrocartilagenous synchondrosis
-Normal radiolucent line
Sensory Nerves Innervation
Trigeminal nerve
- Maxillary nerve
a. Infraorbital nerve
-Alveolar branches
b. Pterygopalatine nerve
-Palatine nerves - Mandibular nerve
a. Inferior alveolar nerve
-alveolar sensory branches
b. Mental nerve
-Mental nerve
Clinical importance
- Maxillary nerve
- Infraorbital nerve
- Inferior alveolar nerve
19.” Mental nerve
Blood supply
Branches of Maxillary Artery
- Inferior Alveolar Artery: courses through mandibular foramen and canal to supply mandibular teeth and bone
-Three mental branches: course through caudal, middle and rostral mental foramena. May encounter when performing surgical extraction of mandibular teeth. - Major and Minor Palatine Arteries: supply hard and soft palate, periosteum, alveolar bone of maxillary teeth
- Infraorbital Artery: continuation of maxillary artery, emerges from infraorbital canal. Several branching
-Alveolar arteries brach and supply the maxillary teeth.
Muscles of Mastication
-Masseter m.
-Temporal m.
-Pterygoid m.
-Digastricus m. (caudal belly, facial nerve)
Trigeminal nerve innervation (Facial branch)
Lecture 3
Periodontal Disease facts
Present in 70-90 % of patients to some degree
Most common cause of oral infection and tooth loss
Preventable disease, but once stablished only managed, chronically progressive
Gingiva
Normal: sharp, thin, non-inflamed margins. Firm, Coral-pink, stippled
-Aerobic gram positive bacteria
Abnormal: marginal gingivitis, rounded edges, erythematous, may bleed upon probing
-Accumulation of calculus/plaque in sub gingival location creates anaerobic environment
-Increased anaerobic, gram negative and spirochete bacteria.
Plaque Induced Gingivitis
-Bacterial plaque colonizes within 24-36 hours after cleaning
-Plaque is inorganic, transparent, adhesive biofilm, salivary glycoproteins, oral bacteria and extracellular polysaccharides.
-If not removed, within a few days, inflammatory response at gingival margin
Gingivitis
What type of bacteria predominates?
What does the inflammatory response consist of?
Normal: sharp, thin, non-inflamed margins. Firm, Coral-pink, stippled
-Aerobic gram positive bacteria
Abnormal: marginal gingivitis, rounded edges, erythematous, may bleed upon probing
-Accumulation of calculus/plaque in sub gingival location creates anaerobic environment
-Increased anaerobic, gram negative and spirochete bacteria.
Inflammation
-Vasculitis
-Edema
-Collagen loss
Diagnosed
-When inflammation is limited to the gingiva
-Advanced gingivitis can develop in periodontitis
Risk factor for periodontal disease
Tissue Destruction
-Black pigmented anaerobic bacteria is commonly associated with periodontitis
Inflammatory factors host’s immune response and anaerobic bacteria cause the destruction of the tissue surrounding the tooth (periodontium)
Risks
-Age: more common in older animals
-Breed: brachycephalic, toy breeds, dolicocephalic breeds
-Persistent deciduous teeth
-Malocclusions
-Genetic predisposition
-Host’s immune response
-Non-abrasive diet
-Chewing habits
-Periodontal trauma
-Oral foreign bodies
Periodontitis Tissue destruction
-Epithelium attachment loses integrity
-Gingival sulcus increases in depth
-Pockets are formed as periodontal ligament and alveolar bone are destroyed
-Gingival recession
-Tooth loss if not treated
Clinical features of Periodontal Disease
-Gingivitis
-Halitosis (bad breath)
-Gingival enlargement
-Gingival recession below neck of tooth
-Periodontal Pockets
-Abscessation (apical tooth abscess)
-Facial swelling
-Draining fistula
-Ophthalmic sequela
-Oronasal fistula - nasal discharge
-Osteomylitis
-Osteolysis
-Mandibular fractures (when bone loss is severe)
-Systemic organ lesions from bacteremia (kidney, liver), chronic pulmonary changes
-Oral pain
-Tooth mobility
How is Periodontal disease assessed and Diagnosed?
What are the stages of PD? How are they determined?
Periodontal probing
-Locating periodontal pockets
-Checking for gingival sulcuses depth
Diagnosis
-Definitive Dx requires general anesthesia
-Dental radiographs
-Periodontal probing
-PD (periodontal disease) refers to degree of severity on a single individual tooth.
Stages 0-4
Attachment Loss Concept
-Refers to the destruction of periodontium (gingiva, cementum, alveolar bone, PDL) due to periodontitis
-Determined by probing, measurement of gingival recession (if present) and radiographs
-Probing depth: mm from gingival margin to the most apical point that the probe reaches when gently inserted into the gingival sulcus or pocket.
Radiograph
-Measure distance from the alveolar margin (AM) to the cementoenamel junction (CEJ) relative to the length of the tooth. Ex: 11/15 = 0.73 = 73% attachment loss
Tooth Root Furcation
Furcation Index Stages 0-4
-Normal space in multicoated teeth
-When disease is present bacteria inhabits the space
Stage 1
-Involvement exits when the probe extends LESS than halfway under the crown in any direction of multicoated teeth with attachment loss
Stage 2
-Involvement exits when the probe extends MORE than halfway under the crown in any direction of multicoated teeth with attachment loss, but not through and through
Stage 3
-Involvement exits when the probe extends under the crown in any direction of multicoated teeth, through and through from one side of the furcation out the other.
-Tooth needs to be extracted bc it’s hard to keep it clean
Periodontal Disease Stages
Normal (PD 0)
-Clinically normal
-Gingival inflammation or periodontitis is not clinically evident
Stage 1 PD
-Gingivitis only without attachment loss
-Height and architecture of the alveolar margin is normal
-Mild gingivitis, mild calculus, no recession
Stage 2 PD
-Early periodontitis or at most there is stage 1 furcation
-Periodontal attachment loss <25%
-Or radiographic determination of the distance of the alveolar margin from the cemento-enamel junction relative to the length of the tooth.
Periodontal Disease
Stage 3
-Moderate periodontitis
-25-50% attachment loss
-Measured by probing of the clinical attachment level, radiographic determination of the distance of the alveolar margin from the CEJ relative to the length of the tooth, or
-There is stage 2 furcation involvement in multi-rooted teeth.
Stage 4
-Advanced periodontal disease
->50% attachment loss or
-Stage 3 furcation
Lecture 4
Indications for Dental Radiography
-Most dental pathology is below the level of the gingiva and cannot be detected through visual examination
-Diagnosis of periodontal disease
-Diagnosis of endodontic disease
-“missing” teeth
-Extractions, prior, maybe during, and after
-Resorptive tooth lesions
-Screening radiographs during routine dental cleaning
-Periorbital swelling, gingival swelling and oral neoplasia
-Developmental abnormalities
-Trauma
-Malocclussions
-Rule out dental cause of “nasal” disease
Dental radiographs
Conventional radiograph unit
-Useful in imaging mandibular/maxillary fractures, trauma, masses, TMJ
-Some practices without dental unit still may have regular unit
-Not great for diagnosis
-Difficult to isolate individual teeth
-Can’t take intra-operative films without moving patient from dental treatment table
-Inconvenient, usually not in location where dental procedures are performed
Dental Radiographs Unit
-kVp and mA are often fixed and only time is selected
-Most units have anatomic interface where operator sets the size and tooth the exposure is adjusted automatically
Radiographic Safety
-Less radiation than conventional units
-Required to be registered and inspected by the State Department of health
-In Virginia, stand >9 feet from the tube when making an exposure
-Stand at angle of 90-135 degrees from primary beam
-Use Disometry badges
-Use positioning aids (e.g., gauze sponge or play dough) to help stabilize the sensor/film to prevent exposure of staff by holding it
Obtaining Image
- Conventional Intraoral film
-Least expensive
-Requires no automation
-Several sizes available
-Takes more time
-Requires developing chemicals
-Must store and catalog films as part of the patient record.
-Processing errors can be a problem - Sensor based radiograph (DR) “digital radiograph”
-Charged-coupled device (CCD)
-Complementary metal oxide semiconductor (CMOS)
-Need #2 sensor, laptop or desktop, software
-Immediate images ~5 sec
-Digital images, easy to store
-More consistent quality
-Less radiation required
-Sensors can be expensive ~$2000
-Only #1 and #2 size available - Photostimulable phosphor plates (CR) “computed radiograph”
-CR reader
-Computer, software
-Phosphos plare
-Available in size 0, 1, 2, 3, 4. May be used in large animals
-Digital images
-#1 plate better for cats
-Quality images
-Slower ~30 sec for images
-Hard-wired sensor
Radiographic Positioning
- Parallel Technique
-Film or sensor is parallel to the long axis of the subject
Distal mandibular (307/407)
-Film sensor can be placed parallel to the tooth and perpendicular to the primary beam - Bisecting angle technique
-Due to anatomical interference with all maxillary teeth
-Sensor can’t be aligned parallel to the long axis of the tooth
-Mandibular rostral teeth also
-Angle is between the plate and perpendicular to sensor angle, and plate and sensor perpendicular to long axis of tooth angle.
Orient primary beam half-way between these those extremes, the image of the tooth will be same as the actual tooth
-Some dental x-ray units come with angle indicators
Dental Radiograph Chart
Corrective techniques for superimposed PM4 maxillary
Foreshortening and Elongation Errors
Other errors
Foreshortening
-X-ray beam is too perpendicular to the sensor beam
-Correction: drop the angle to a more lateral position
Elongation
-The beam is too perpendicular to the tooth
-Correction: increase the angle to a more vertical position
Lecture 5
What are the components of the periodontium?
What is its function?
The function is to provide both structural and functional anchorage for the teeth within the mandible and maxilla
- Gingiva
- Periodontal ligament
- Cementum
- Alveolar bone
Pathogenesis of periodontitis
-Pellicle: protein film consisting of salivary glycoproteins which form within seconds of the teeth being cleaned
-Plaque biofilm: bacterial pellicle forms within 24 hours
-Calculus: forms via mineralization of the plaque biofilm by ions in the saliva. It is detectable within 48-72 hours after cleaning.
-Mechanical removal of the biofilm is required to prevent and treat periodontal disease
-supragingival bacteria influence the growth and pathogenicity of subgingival bacterial population
What are some locoregional and systemic periodontal disease?
Locoregional
-Periapical abscesses
-Oronasal fistula: +/- chronic rhinitis
-Retrobolbulbar cellulitis/ophthalmic inflammation
-Epiphora (insufficient tear drainage/blockage): due to compression/inflammation of nasolacrimal duct
-Pathologic fracture of the mandible in small/toy breed predisposition.
Systemic
-Bacteremia
-Kidney damage
-Liver damage
-Cardiovascular damage (myocardium)
-Left atrioventricular valve
Symptoms & PE findings & Diagnosis
Symptoms
-Reluctance to chew
-Head shyness
-Pawing at the face
-Dropping food when eating
-Sneezing/nasal discharge
-Exaggerated jaw motion when chewing
-Aversion to food or water
Most patients still eat with severe periodontal disease
PE findings
Intraoral
-Halitosis
-gingivitis
-Calculus
-Gingival recession/root exposure
-Missing teeth
-Mobile teeth
Extraoral
-Submandibular swelling
-Periorbital swelling
-Draining tracts
Diagnosis (can’t Dx on awake oral exam alone)
Minimum database
-CBS
-Chemistry profile with electrolytes
-UA with USPG if renal values borderline
-Species specific with ELISA testing: HWT, FIV/FeLV
Comprehensive Oral Health Assessment and Treatment (COHAT)
-Requires anesthesia
-Requires imaging
Dental radiographs is the standard of care Cone beam Computed Tomography for advanced diagnosis
-Probe Exam
-Dental chart for documentation in addition to written SOAP notes
Diagnostic Terminology
Stage: Periodontal disease
-Assessment of the extent of pathological lesions in the course of the disease. Ex: stages of periodontal disease, stages of oral tumor.
Grade: Furcartion Exposure
-The quantitative assessment of the degree of severity of a disease or abnormal condition at the time of diagnosis, irrespective of wether the disease is progressive (e.g., a grade 2 mast cell tumor based on mitotic figures)
Index: Gingivitis
-A quantitative expression of predefined diagnostic criteria whereby the presence and/or severity of pathological conditions are recorded by assessing a numerical value (e.g., gingival index, plaque index)
Diagnosis: Furcation Index
Stage 1 (F1)
-Furcation 1 involvement, periodontal probe extends less than halfway in any direction of multirooted tooth
Stage 2 (F2)
-Periodontal probe extends >halfway under the crown of a multirooted tooth WITH attachment loss, but not through and through
Stage 3 (F3)
-Periodontal probe extends under the crown of any multirooted tooth, through and through from one side to the other.
Diagnosis: Mobility Index
Stage 0 (M0)
-Physiological mobility up to 0.2 mm
Stage 1 (M1)
-Increased mobility in any direction other than axial >0.2mm up to 0.5mm
Stage 2 (M2)
-Increased mobility in any direction other than axial >0.5mm up to 1mm
Stage 3 (M3)
-Increased mobility in any direction other than axial >1mm
Diagnosis: Gingivitis Index (up for debate)
Gingival Index 1
-Inflammation and swelling, NO bleeding during periodontal probing
Gingival Index 2
-Inflammation and swelling, With bleeding during periodontal probing
Gingival Index 3
-Inflammation and swelling, spontaneous bleeding during periodontal probing
Diagnosis: Periodontal Disease Stages
Normal (PD0)
-0% attachment loss, 0 gingivitis
Stage 1 (PD1)
-0% attachment loss, gingivitis present
Stage 2 (PD2)
- <25% attachment loss
-Stage 1 furcation involvement
Stage 3 (PD3)
- > 25% up to 50% attachment loss
- Moderate periodontitis
-Stage 2 furcation involvement
Stage 4 (PD4)
- > 50% attachment loss
-Advanced periodontitis
-Stage 3 furcation involvement
Diagnosis: Probe Exam
-Performed after dental radiographs during COHAT
-Requires periodontal probe
-Requires dental chart to record findings
A. Marquis color-coded probe
-Calibrations are in 3mm sections
-Dog only
B. University of North Carolina-15 Probe
-15mm long probe
-With millimeter markings at each millimeter
-Color coding at 5th, 10th, and 15th millimeter
-Cat or dog
C. University of Michigan “O” probe with Williams marking
-Markings at 1,2,3,5,7,8,9, and 10mm
Requires dental chart to record findings
Measuring a periodontal pocket with probe
What is the normal pocket depth in a dog and cat?
Normal
-Dog: 1-3mm
-Cat: <1mm
1.Gently place the probe between the gingiva and tooth
2. Stop when you feel resistance
3. Record the pocket depth
Do not use too much force, can cause damage and create an accidental pocket
Treatment Options
Surgical
-Requires referral (except certain extractions)
-Defined as any procedure requiring a mucogingival flap
-Examples: open root canal, bone grafting, etc.
Non-Surgical
-Can be performed at a general practice
-Ultrasound scaling and polishing
-Closed root planning (with or without perioceutic application)
-Barrier/sealant application
-Homecare
Perioceutics
Parioceutics
-Antimicrobial products available for dental application (FDA approved on non lactating dogs)
8.5% doxycycline
-Powder contained within a slowly dissolving polymer gel
2% Clindamycin
-Hydrated salt in a matrix that gels at body temperature
Act as a physical barrier to pocket contamination, doxycycline in addition has anticollagenase activity
-Local Infusion of antibiotics
PD2, PD3 Treatment
Root planning
-Closed
-Open
-With or without perioceutic application
-Tools: Gracey, Universal curettes. 5-0 Monocryl to close ALL periodontal surgeries
**Run the curette along the surface of the tooth into the periodontal pocket, “hook” the granulation tissue and calculus, scrape upward along the tooth to remove debris.
Bone grafting
-Performed to maintain alveolar bone height
Guided Tissue Regeneration (GRT)
Mucogingival flap osseous countouring/recontouring
Advanced Procedures:
Bone Grafting
GTR
Bone Grafting
-Osteoconductive: materials that occupy space and acts as scaffold on which new bone can grow
-Osteoinductive: contains growth factors or hormones that signal host to produce new bone
-Bioceramic: Osteoconductive, Flap dehiscence. Ex: CONSIL
-Autologous: Osteoinductive and osteoconductive, preferred grafting material. Ex: SYNERGY, PERIOMIX
-Autogenous: Grafter from patient themselves, best integration, lowest risk of rejection. Osteogenic, osteoconductive, osteoinductive.
Guided Tissue Regeneration
-Allows for regeneration of the periodontal tissue, rather than repair.
-Requires recheck under anesthesia with dental radiographs in 6 months to monitor osseous integration
Lecture 6
Endodontics
-The study (practice) of the basic and clinical sciences of normal DENTAL PULP
-Etiology, diagnosis, prevention, and treatment of diseases and injuries of the dental pulp along with associated PERIARDICULAR conditions
What are the 4 major tissue components of the tooth?
- Enamel
- Dentin
- Pulp
- Cementum
Apical delta
Cemetoenamel junction
Alveolar Bone
Symptoms Tooth Fractures
TDI
(66% Considered severe injuries with significant consequences if not treated promptly)
-Halitosis
-Dropping food
-Reluctance to play with toys
-Lethargy
-Inappetence
-Facial swelling
-Hypersalivation
-Maxillofacial trauma: 75% cases at least 1 TDI
-Most TDIs are incidental findings
Second most common oral disease to periodontal disease
-Canine>premolar>incisor>molar
-Most common PM4>canine>incisor>molar
Non-vital Teeth
Treatment Options
Fractures Treatment Option
Important Questions
What type of fracture?
When did the trauma occur?
Is the tooth vital or non-vital?
Is the apex open or closed?
Endodontic Treatment
-Standard root canal therapy
-Surgical root canal therapy
-Vital Pulp therapy: Complicated crown fractures <48 hours old.
-Odontoplasty and restoration
-Indirect pulp capping
TDIs
-Acute avulsion where owner recovers tooth: place tooth in milk and replace in alveolus within 24 hours
-Avulsions >24hrs: unlikely to save tooth
-Subluxation/Luxation: combination of intraoral splint and root canal therapy
Lecture 7
Anatomy Review
Gingivitis: inflammation of the gingiva
Mucositis: inflammation of the alveolar and buccal mucosa
Alveolar mucositis: inflammation of the gingiva and mucosa overlying the cheek teeth.
Caudal stomatitis: inflammation of the mucosa lateral to the palatoglossal arches
-Pathognomonic for FCGS
Faucitis: incorrectly refers to inflammation in the area lateral to the palatoglossal folds.
Glossitis: inflammation of the tongue
Palatitis: inflamation of the palate
Erythema Multiforme
-Uncommon
-Vesiculobullous and/or ulcerative skin disease
-Non-specific gingivitis and stomatitis can mimic this disease
-Affected areas include intraoral and extraoral sites: ventrum of trunk, footpads, ponnae, glossitis, etc.
Lupus Erythematosus
-Discoid lupus erythematosus, mucocutaneous lupus
-DLE: linchenified, crusted, depigmented, and ulcerated lesions nasal planum, perioral, periocular, and pinnal leisons
-SLE: acute lesions on mucosa, skin and ORGANS
Pemphigus vulgaris (PV)
-RARE
-Middle age dogs, SEVERE
-Antibodies against Desmoglein-3 at the base of the epidermis and oral mucosa
-Hard palate, gingiva, dorsal tongue affected
-Mucocutaneous junction affected
-Oral lesions before skin lesions occur in about 50% of the cases
-Characterized by fragile vesicles, patchy areas of ulceration, crusting and inflammation quickly follow when vesicles rupture and slough
-Subtypes: Paraneoplastic pemphigus has been described in rare cases in dogs
Eosinophilic Granuloma Complex in Cats
-Oral mucosa, lip, tongue, and palate
-Histopath characteristic presence of Eosinophilic infiltrates
-Lesions are typically linear, well-circumscribed, raised, yellow-pink color
-May be seen in the skin, paws, cheek, lip commissure, chin, pinna of the ear and oral cavity.
-“POUTING” look in the cat from lesions
-C/S: Dysphagia, or ptyalism, interference with swallowing
More common in 2-6 yrs old
Higher incidence in females
Associated with
-Insect bites allergies
-Food allergy
-Atopy
-Immunosuppression
-Bacterial and viral (Calicivirus) infections
Eosinophilic Ulcer, usually concave when indolent
-Granular orange-yellow color upper lip near the philtrum (rodent ulcer)
Eosinophilic Stomatitis in DOG
-Palatal lesions mostly
-Less involvement of the tongue
Cavalier King Charles Spaniels = dysphagia, paroxysmal coughing or anorexia. Mucosal ulceration, plaque formation and granulomatous lesions. Familial predisposition
Siberian Huskies
-Palatal lesions = no clinical signs
-Young 1-7 yrs old
-Treatment same as cats: Corticosteroids or surgical excision
-May be recurrent
Oral Eosinophilic Granuloma
Siberian Huskies
-Believed to be hereditary or familial
-Usually on the tongue, palatal mucosal
-Halitosis and oral discomfort
Wegner’s Granulomatosis
-Uncommon
-Autoimmune inflammatory disorder
-C5a complementary system inhibition role in pathogenesis
-Multifocal, bruised, erythematous, expansible, friable gingival lesions
Grossly looks like Neoplasm
-Severe alveolar bone loss on radiographs
-Presence of GRANULOMATOUS inflammation, NOT secondary to fungal or infectious
-DDX: traumatic granuloma, necrotizing ulcerative stomatitis, pyogenic granuloma, neoplasia, immune-mediated conditions.
Hyperparathyroidism Dogs
AKA: Rubber jaw, renal osteodystrophy, Fibrous osteodystrophy, Osteodystrophia Fibrosa
-Primary hyperthyroidism functional adenoma
-Secondary hyperthyroidism as a result of diet with low calcium-to-phosphorous ratio such as all meat diets.
Radiographic findings are pathognomonic of disease
-Pathophysiology: low phosphorous or low calcium:phosphorous ratio. In renal insufficiency the reabsorption of phosphate is impaired, which results in hyperphosphotemia.
-Hyperphosphotemia a decreased blood calcium stimulates parathyroid gland activity
-Concurrently the synthesis of 1,25-dihydroxyvitamin D in the kidney is also decreased, an intestinal calcium absorption and impaired mineralization of osteoid.
Congenital Hypothryroidism Cats
-RARE
-Darwfism, soft coat, wide eyes, flat face, delayed skeletal growth, dull mentation (depressed, less alert)
-Historically megacolon and obstipation as primary presenting complain
-Treatment: Levothyroxine and Gingivectomy to allow normal dental eruption
Mentation Reminder
1) Bright, Alert and Responsive (BAR)–self explanatory. This is normal mentation.
2) Depressed or obtunded–the depressed pet is dull or less responsive to normal stimuli.
3) Stuporous–this means the pet is unresponsive until a noxious or painful stimulus is applied.
4) Comatose–this means the pet remains unresponsive with even a noxious or painful stimulus.
Lecture 8
Interpretation of Dental Radiographs
Orientation
Orientation Mandible
Orientation Mandible
Orientation Maxilla
Root anatomy
Periodontal disease Percent attachment bone loss
Periodontal disease
Periodontal disease
Periodontal disease
Periodontal disease
Periodontal disease
Endodontic disease
Endodontic disease
Normal Lamina Dura
Normal Lamina dura
Evaluation of Lamina Dura
Periapical Lucency
Tooth Resorption
Tooth Resorption
Tooth Resorption types based on radiographs
Tooth Resorption Based on Radiographs
Tooth Resorption Based on Radiographs
Tooth Resorption in Dogs
-Most often in mandibular premolars
-Often begins in the roots
-If it doesn’t extend beyond the level of gingiva, can monitor
-If extends into crown or is communication with oral cavity = extract, painful
-Roots can be ankylosed (fused, immobile)
Radiographs and Extractions
Pre-extraction
Pre-extraction radiographs
Pre-extraction radiographs
Lecture 9 Oral Pathology 2
Review Key-terms
-Sarcoma: characterizes tumors that arise from non-epithelial tissue
-En bloc: a procedure in surgical oncology aiming to remove a tumoral mass in its entirety, completely surrounded by a continuous layer of healthy tissue
-Palliative: palliative treatments aim to shrink cancer, slow down its growth or control symptoms, NOT cure
-Definitive: therapy aimed to minimize the long-term adverse effects of therapy and to enhance the long-term control of the cancer. Definitive intent radiation therapy generally means that small dosages of radiation are administered daily over 2-4 weeks.
Neoplasia of the Oral Cavity
Overview of Diagnosis and Treatment
Minimum database
-CBC
-Chemistry profile with electrolytes
-UA with USPG if renal values are borderline
-Species specific ELISA test: HWT, FIV/FeLV
-Comprehensive Oral Health Assessment and Treatment (COHAT) requires anesthesia, imaging.
-Cone beam radiograph for advanced diagnostics
-Perform punch biopsy for for definitive diagnosis
-Request pathologist familiar with oral path
Treatment
-Local control of disease via surgery
-Aggressiveness of surgery is determined by tumor type
Peripheral Odontogenic Fibroma
Second most common odontogenic tumor AKA “Epulis”
-Slow growing, bening, firm, sessile (immobile, attached, no stalk) to pedunculated (stalk present), non-ulcerated lesion
-Usually associated with free gingiva of tooth
-NOT invasive
-No predilection sex, age, breed or jaw location
-Can lead to secondary periodontitis
-Traumatized during mastication possible
1. Fibromatous: only soft tissue
2. Ossifying: osseous metaplasia
Create pseudopocket
Diagnostics
-Radiographs: soft tissue inflammation minimal osseous tissue involment
-Histopath: Base of proliferative neoplasia, FIBROUS tissue anchored to the periosteal surface of the alveolar crestal bone near the CEJ with NO PDL involvement
Treatment
-En bloc resection of tumor and associated tooth/teeth
-More aggressive Tx for recurrent cases
Canine Acanthomatous Ameoblastoma
Most common OT in dogs
-Not seen in cats
-Locally infiltrative, NOT metastatic
-Commonly appear as extraosseous inflammation with or without tooth displacement and bone invasion
-Arises from odontogenic epithelium in gingiva of tooth-bearing areas of JAWS
-Location: rostral mandible»mandible>maxilla
Infiltration into surrounding bone, which makes it different from Central Ameloblastoma
Golden Retriever, Akita, Crocker, Sheltie
Radiographs
-Bone infiltration
-Alveolar bone resorption
-Tooth displacement
CT
-Interosseous cystic and appeared subjectively more aggressive than extraosseous
Histology
-Islands and sheets of mature cells that are clearly squamous epithelium.
-PALISADING cells bonded to island sheets…
Treatment of choice
-Current recommendations is wide excision (en bloc) with 1cm margins
Excellent prognosis with wide local exc
Odontoma
-Bening, inductive tumor
-6-18 mts of age
-Cats and dogs
-Well differentiated cells
-Non-painful, expansile, MN or MX
-Associated with UNERUPTED tooth
-Alveolar inflammation
- Compound odontoma
-Tooth-like structures
-Orderly pattern
-DENTICLES on radiographs - Complex odontoma
-Didorderly dental tissue
Radiographs
-Well defined tumor mass calcified material
Treatment
-Marginal excision or even intracapsular may be curative
Amyloid-Producing Odontogenic Tumor
APOT
-RARE
-Suspected derived from ameloblasts
-Gingival enlargement
-Slow growing expansile mass
-Middle age to older dogs
Radiographs
-Unilocular to multilocular radiolucency
-Cystic appearance
Treatment
-Surgical resection with 1 cm margin appears to be curative in most cases
-Enucleation alone = high recurrence
Feline Inductive Odontogenic Tumor
FIOT
-8-18 mts of age
-Inductive bc epithelium induces mesenchymal cells to form aggregated foci of dental pulp-like cells
-Raised, submucosal, rapidly expansive, locally destructive, soft tissue masses
-Usually unilateral on rostral maxilla
-Does not metastasize
Treatment
-Wide excision is curative
Feline “Epulides”
-Term applies to a variety of gingival masses in the cat
-Combination of fibromatous, ossifying, and acanthomatous (small red raised growth) features
Treatment
-Surgical management recommended, but challenging
-High recurrence rate
-Some cases may require multiple extractions and gingivectomy
Papillary SCC
-Maybe Papillomavirus association
- <2-5mts of age in dogs
- Adults up to 9 yrs also can be affected
-Locally aggressive, with underlying bone lysis
-Responds well to surgery and orthovoltage radiotherapy combined
-NO reports of METASTASIS
- Intraosseous: within the jaw bone (cavitating pattern = deep erosion, valley-like)
- Exophytic: mass grossly similar to benign papilloma (non-cavitating pattern)
Treatment
-Surgical excision with 1cm margin may be curative
Oral Malignant Melanoma
-One of the most common oral malignancies
#1 Most common in Dogs
-Gingiva, labial mucosa, palate, buccal mucosa, tongue.
-Typically firm, grayish or brownish black, can also lack pigment
-Ulcerative, friable, readily bleeds
-Fast growing
-NECROSIS common feature
-Gingival tumors have the worst prognosis
Treatment
-Surgical resection for locoregional control
-1 cm margins may be curative
-May follow up with radiation
-METASTATIC high rate to lymphnodes and lungs
-Vaccine questionable efficacy
Prognosis
-Highly dependent on size at time of surgery
-Variable
Fibrosarcoma
3rd most common malignant tumor in the DOG
2nd most common malignant tumor in the CAT
-More common in large breed dogs
-Average age 8 yrs old
-Lesions in gingiva, hard palate, labial mucosa, soft palate, tongue.
-Tends to present in broad-based, firm swelling.
Radiographs
-Infiltrative: challenging to discern full extent of tumor even with advanced imaging
Treatment
-Aggressive surgery 2cm margins
-Post surgical radiation combined, best outcome
-High level of local recurrence with surgery alone
Osteosarcoma
-Often present as soft tissue mass
-Red, friable, surrounding bone lysis rather than hard tissue proliferation
-OSA - more common in appendicular than axial skeleton
-Maxilla and mandible commonly affected sites
Treatment
-Surgery: median survival 9mts
-28% local recurrence in dogs
-Chemo NOT useful
-Radiation therapy may be helpful
Cats
-Poor prognosis as surgical options are limited
Benign non-odontogenic Tumors
Papilloma
-Young dogs
-Multiple verrucous lesions on the tongue, lip, and cheeks.
-“SEA ANEMONE” appearance
Treatment
-Most regress on their own
-Cleated by immune system
-Refractory cases: concurrently immunocompromised
-Vaccine may be helpful
Osteoma
-Can occur in dogs or cats
-Well circumscribed, firm raised boney lesions
-Located in hard palate, zygomatic arch, caudal mandible
Histiopath
-May not show neoplasia characteristics
-May show normal woven bone
Treatment
-Surgery
-Maxillectomy, mandibulectomy, debulking all resulted in > 1 yr survival
Plasmacytoma
-RARE
-Well circumscribed red mass often <1 cm
-Biologically more aggressive than cutaneous counterparts
-May undergo local invasion to underlying bone
Treatment
-Surgical margins 1 cm have been curative
Lecture 10 Extractions
Review Anatomy
Which teeth are two rooted, three rooted, one rooted?
Review Anatomy
One root
-Incisors (01-03)
-Canine (04) 104, 204
-PM1 (05)
-M3 (11) mandible
Two Roots
-PM2 (06), PM3 (07), PM 4 (08), M1 (09), M2 (10) Mandible
-PM2 (06), PM3 (07) Maxilla
Three Roots
-PM4 (08), M1 (09), M2 (10) Maxilla
Cats
-PM2 (06), PM3 (07), M1 (09) Maxilla - Two Roots
-PM4 (08) Maxilla - Three Roots
Equipment and Intruments
A. Minnesota lip retractor
B. Feline lip retractor
C. Miller bone curette
D. Periosteal elevator
E. Straight and winged elevators
F. Small breed extraction forceps
G. Needle holders
H. Iris scissors
I. Thumb forceps
J. Scalpel blade handle
-High speed hand piece: used to modified pen grasps, resting figure on patient
-Burs: Round burs, taper fissure crosscut burs, Diamond burs.
-#15 or 15C scalpel blade
-Root tip pick
-Root tip extraction forceps (small tips)
-Miller bone curette for debriding granulation tissue, bone fragments, debris in alveolus
-Suture: 4-0 or 5-0 Monocryl, reverse cutting or tapered needle
Biomechanical Principles for Extractions
Elevators = Levers
-Transmit a modest force into a small movement against great resistance. Mechanical advantage
-Rotation of elevator in PDL space utilizes the surrounding alveolar bone as a fulcrum
Elevator is never placed or used adjacent to teeth that will not be extracted
Luxator = Wedges
-Wedged into PDL space and pressure is directed apically
-Made of softer metal and can’t be used as a lever
- Elevator
- Luxator
- Extraction forceps: Leverage
Twist once and pull down and out in a continuous movement
Dental Machine
High-speed hand piece
Air supply
Different Burs
Surgical Principles and Techniques
Flap Design
-Good exposure: sufficient size
-Preserve blood supply: wide base compares to free margin
-Prevent dehiscence/delayed healing: edges of flap must lie over intact bone
-Non-tension closure: make vertical releasing incisions at line angles of adjacent teeth vs. parallel to allow for large non-tension flap
Principles of Suturing Oral Mucosa
A. Insert at 90 degree angle
B. Rotated to easily pass through tissue
Patient Preparation
-Intraoral radiographs PRIOR to any tooth extraction REQUIRED
-Post-extraction intraoral dental radiographs REQUIRED
Simple Extractions Tips/Tricks
Surgical Extractions
-Requires gingival incision, bone removal, and or sectioning of the tooth
-Technically can apply to any tooth
-Commonly PM4 maxilla
-M1 mandibular
-Canine teeth
-Others not affected by advanced stage periodontal disease
PM4 Maxillary
Indications: fracture, periodontal disease, non-vital tooth
-15 blade, create incision for mucoperiosteal flap
-Using periosteal elevator, elevate gingiva and mucosa off tooth and alveolar bone
-Using either a diamond bur or 2-, or 4-, round bur, remove alveolar bone to expose the mesial and distal roots. Typically recommended to remove coronal 2/3 of alveolar bone
-Using cutting but (701, 701L) section the tooth into 3 positions along root segments.
-Using elevation technique of choice, remove each root individually. Remove distal, then mesial-buccal, then messial-palatal
-Using a diamond bur (smoothing bur) remove sharp edges of alveolar bone (Alveoloplasty)
-Using iris scissors perform a periosteal releasing incision on mucogingival flap to ensure tension-free closure
-Suture the flap closed in simple interrupted suture pattern using 4-0 MONOCRYL in dogs and 5-0 MONOCRYL in cats.
Surgical Extractions 2-Rooted tooth
Indications: fracture, periodontal disease, non-vital tooth
Watch out for mandibular canal, periodontal risk for jaw fracture M1
-15 blade, create incision for mucoperiosteal flap
-Using periosteal elevator, elevate gingiva and mucosa off tooth and alveolar bone
-Elevate lingual mucosa as well as either before or after extraction for tension-free closure
-Using either a diamond bur or 2-, or 4-, round bur, remove alveolar bone to expose the mesial and distal roots. Typically recommended to remove coronal 1/2 of alveolar bone
-Using cutting but (701, 701L) section the tooth into 2 positions along root segments.
-Using elevation technique of choice, remove each root individually. Remove distal, then mesial-buccal, then messial-palatal
-Using a diamond bur (smoothing bur) remove sharp edges of alveolar bone (Alveoloplasty)
-Using iris scissors perform a periosteal releasing incision on mucogingival flap to ensure tension-free closure
-Suture the flap closed in simple interrupted suture pattern using 4-0 MONOCRYL in dogs and 5-0 MONOCRYL in cats.
Surgical Extraction Maxillary Canine
Indications: Fracture, periodontal disease, non-vital tooth
Watch out for penetration into the nasal cavity
-15 blade, create incision for mucoperiosteal flap
-Using periosteal elevator, elevate gingiva and mucosa off tooth and alveolar bone
-Using either a diamond bur or 2-, or 4-, round bur, remove alveolar bone to expose the mesial and distal roots. Typically recommended to remove coronal 1/2 of alveolar bone
-Careful accidental iatrogenic ONF formation
-Using elevation technique of choice, remove the tooth.
-Can use butting bur (701, 701L) to “notch” either side of the alveolus (socket) at the level of the CEJ to create space to place your elevator or luxator
-Using a diamond bur (smoothing bur) remove sharp edges of alveolar bone (Alveoloplasty)
-Using iris scissors perform a periosteal releasing incision on mucogingival flap to ensure tension-free closure
-Suture the flap closed in simple interrupted suture pattern using 4-0 MONOCRYL in dogs and 5-0 MONOCRYL in cats.
Surgical Extraction of Mandibular Canine
Indications: Fracture, periodontal disease, non-vital tooth
Watch out for mandibular canal, potential risk for mandibular fracture
Never remove bone on the lingual aspect of the tooth = JAW FRACTURE
-15 blade, create incision for mucoperiosteal flap
-Using periosteal elevator, elevate gingiva and mucosa off tooth and alveolar bone
-Using either a diamond bur or 2-, or 4-, round bur, remove alveolar bone to expose the mesial and distal roots. Typically recommended to remove coronal 1/2 of alveolar bone
-Using elevation technique of choice, remove the tooth.
-Can use butting bur (701, 701L) to “notch” either side of the alveolus (socket) at the level of the CEJ to create space to place your elevator or luxator
-Using a diamond bur (smoothing bur) remove sharp edges of alveolar bone (Alveoloplasty)
-Using iris scissors perform a periosteal releasing incision on mucogingival flap to ensure tension-free closure
-Suture the flap closed in simple interrupted suture pattern using 4-0 MONOCRYL in dogs and 5-0 MONOCRYL in cats.
