Small Animal Dental, Oral & Maxillofacial Disease A Color Handbook Brook A. Niemiec Diplomate, American Veterinary Dental College, Fellow, Academy of Veterinary Dentistry Southern California Veterinary Dental Specialties, San Diego, USA vetdentalrad.com MANSON PUBLISHING/ THE VETERINARY PRESS Copyright © 2010 Manson Publishing Ltd ISBN: 978-1-84076-108-5 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the written permission of the copyright holder or in accor- dance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 33–34 Alfred Place, London WC1E 7DP, UK. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. A CIP catalogue record for this book is available from the British Library. For full details of all Manson Publishing titles please write to: Manson Publishing Ltd, 73 Corringham Road, London NW11 7DL, UK. Tel: +44(0)20 8905 5150 Fax: +44(0)20 8201 9233 Website: www.mansonpublishing.com Commissioning editor:Jill Northcott Project manager: Kate Nardoni Copy editor: Ruth Maxwell Book design and layout: Ayala Kingsley, DiacriTech, Chennai, India Colour reproduction:Tenon & Polert Colour Scanning Ltd, Hong Kong Printed by:New Era Printing Co. Ltd, Hong Kong Dedication 3 This book is dedicated to all who have helped me to become someone who could write/edit a book worth reading. There are numerous veterinarians who have influenced my life and my career. From my first dental mentor, Dr. Michael Floyd, I learned not only dentistry, but also how to practice while still enjoying a balance of fun in life. Special thanks to my true mentor and founding member of the AVDC, Dr.Thomas Mulligan. Fortunately, you saw promise in me and worked diligently to bring it out, even if I was reluctant initially. Thank you for taking me under your wing and teaching me to be my best, through all those late nights at Main Street. However, veterinary medicine is more than dentistry. I would like to thank Dr. Barry Neichin, my first employer and the best general practitioner I know, for teaching me the basics of veterinary medicine. Drs. Michael Kelly and Robert Tugend continued that training and taught me that working in a team is rewarding. Finally, I would like to thank Dr. Robert Rooks, from whom I gained skills in marketing and client communications. In addition to the veterinarians who have helped me along the way, I have benefited from working with a great group of technicians and assistants. First and foremost in this group is Dawn Sabatino, my right hand (and occasionally my left) for the last decade. So much of my practice would not be possible without you; thanks for all that you do. I owe many thanks to Robert Furman (soon to be a veterinarian) who was instrumental in starting my dental practice as well as making my life easier with his computer and electrical and handy man skills. A note of thanks is also due for my assistants who went above and beyond in years past: Teresa, Wendy, Tia, and Diane. Outside of veterinary medicine, I would like to thank and recognize my original inspiration and uncle, Dr. Greg Steiner DDS, who told me back in the 1980s to do veterinary dentistry! A special note of gratitude to my old adventure buddy, Lynel Berryhill, whose support and technical help during my applications to the Dental College and Academy were invaluable. I couldn’t have done it without you. I also owe a big thank you to Dr. Katie Kangas for her countless hours of editing. This has greatly improved your (the readers’) experience. And finally, this book is largely dedicated to my parents Jim and Toni. Without your emotional and financial support, my years of school, training, and practice would not have been possible. Thank you for going above and beyond as parents, friends, and business mentors. You’re the best! Thanks to all of you for the contributions you have made to my life, which in turn have led to the creation of this book. Brook CONTENTS 4 Foreword . . . . . . . . . . . . . .6 Step 6:Developing the Complicated crown fracture radiograph . . . . . . . . . . . .69 (open crown fracture) . .130 Preface . . . . . . . . . . . . . . . .7 Step 7:Techniques for various Caries (cavity, Abbrevations . . . . . . . . . . . .8 individual teeth . . . . . . . .72 tooth decay) . . . . . . . . .133 Step 8:Interpreting dental Type 1 feline tooth CHAPTER 1 radiographs . . . . . . . . . . .79 resorption (TR) . . . . . . .136 Anatomy and Type 2 feline tooth resorption Physiology CHAPTER 4 (TR) . . . . . . . . . . . . . . .138 Canine dental anatomy . . . . .10 Pathology in the Pediatric Enamel hypoplasia and hypocalcification . . . . . .140 Feline dental anatomy . . . . . .12 Patient Dental abrasion . . . . . . . . .142 Rodent and lagomorph Persistent deciduous dental anatomy . . . . . . . .13 teeth . . . . . . . . . . . . . . . .90 Dental attrition . . . . . . . . . .144 Dental terminology . . . . . . .14 Fractured deciduous External resorption . . . . . . .146 Tooth development . . . . . . .17 teeth . . . . . . . . . . . . . . . .93 Internal resorption . . . . . . .148 Enamel, dentin, and pulp . . .18 Malocclusions (general) . . . .95 Intrinsic stains (endogenous Deciduous malocclusions . . .96 stains) . . . . . . . . . . . . . .149 Periodontium . . . . . . . . . . . .20 Class I malocclusions . . . . . .98 Extrinsic stains (exogenous Bones of the face and jaws . . .22 stains) . . . . . . . . . . . . . .151 Mesioversed maxillary Muscles, cheeks, and lips . . . .26 canines (lance effect) . . .100 Primary endodontic lesion with Neurovascular structures . . .28 secondary periodontal Base narrow canines . . . . . .102 disease . . . . . . . . . . . . . .152 Joints of the head . . . . . . . . .31 Class II malocclusion Primary periodontal lesion with Hard and soft palates . . . . . .32 (overshot, mandibular secondary endodontic Tongue . . . . . . . . . . . . . . . .34 brachygnathism) . . . . . .104 involvement . . . . . . . . .153 Salivary glands . . . . . . . . . . .36 Class III malocclusion Combined endodontic and Lymph nodes and tonsils . . .38 (undershot) . . . . . . . . . .106 periodontal lesion . . . . .155 Class IV malocclusion Idiopathic root (wry bite) . . . . . . . . . . .108 resorption . . . . . . . . . . .156 CHAPTER 2 Cleft palate . . . . . . . . . . . . .110 Oral Examination Cleft lip (harelip) . . . . . . . .112 CHAPTER 6 Step 1:History . . . . . . . . . .40 Tight lip . . . . . . . . . . . . . . .113 Problems with Step 2: General physical Hypodontia/oligodontia and the Gingiva examination . . . . . . . . . .41 anodontia (congenitally Step 3:Orofacial missing teeth) . . . . . . . .114 Gingivitis . . . . . . . . . . . . . .160 examination . . . . . . . . . .42 Impacted or embedded Periodontitis . . . . . . . . . . . .164 Step 4:Conscious (awake) (unerupted) teeth . . . . .116 Generalized gingival intraoral examination . . . .44 Dentigerous cyst enlargement (gingival Step 5:The anesthetized (follicular cyst) . . . . . . . .118 hyperplasia) . . . . . . . . . .170 orodental examination . . .54 Odontoma . . . . . . . . . . . . .119 Trauma . . . . . . . . . . . . . . .172 Hairy tongue . . . . . . . . . . .121 Epulids . . . . . . . . . . . . . . . .173 CHAPTER 3 Enamel hypocalcification Gingivostomatitis (caudal Veterinary Dental (hypoplasia) . . . . . . . . . .122 stomatitis) in cats . . . . .176 Radiology Feline juvenile (puberty) gingivitis/periodontitis .124 CHAPTER 7 Step 1:Patient positioning . . . . . . . . . . .64 Oral papillomatosis . . . . . . .126 Pathologies of the Oral Mucosa Step 2: Film placement within the patient’s mouth . . . . .64 CHAPTER 5 Oronasal fistula . . . . . . . . . .184 Step 3:Positioning the beam Pathologies of the Dental Eosinophilic granuloma head . . . . . . . . . . . . . . . .65 Hard Tissues complex . . . . . . . . . . . .186 Step 4: Setting the Uncomplicated crown Chronic ulcerative paradental exposure . . . . . . . . . . . . .67 fracture (closed crown stomatitis (CUPS) Step 5:Exposing the fracture) . . . . . . . . . . . .128 (kissing lesions) . . . . . . .189 radiograph . . . . . . . . . . . .68 CONTENTS 5 Immune-mediated Fractures . . . . . . . . . . . . . .207 Osteosarcoma . . . . . . . . . . .235 diseases affecting the Traumatic tooth avulsion and oral cavity . . . . . . . . . . .192 luxation . . . . . . . . . . . . .214 CHAPTER 10 Uremic stomatitis . . . . . . . .194 Root fractures . . . . . . . . . . .216 Pathologies of the Candidiasis (thrush) . . . . . .195 Osteomyelitis . . . . . . . . . . .217 Salivary System Caustic burns of the oral cavity . . . . . . . . . . . . . . .197 Tumors and cysts . . . . . . . .218 Sialoceles . . . . . . . . . . . . . .238 Hyperparathyroidism . . . . .221 Salivary gland tumors . . . . .240 CHAPTER 8 Tetanus . . . . . . . . . . . . . . .222 Sialoliths (salivary stones) . .241 Botulism . . . . . . . . . . . . . .224 Problems with Muscles, Bones, and Joints Masticatory myositis . . . . . .200 CHAPTER 9 Appendices ........243 Malignant Oral Neoplasia Craniomandibular osteopathy . . . . . . . . . .202 Introduction . . . . . . . . . . .226 References .........249 Idiopathic trigeminal Malignant melanoma . . . . .228 neuritis . . . . . . . . . . . . .204 Fibrosarcoma . . . . . . . . . . .230 Temporomandibular joint Squamous cell carcinoma . .232 Index .............267 luxation . . . . . . . . . . . . .205 Histologically low-grade, Temporomandibular joint biologically high-grade, dysplasia . . . . . . . . . . . .206 fibrosarcoma . . . . . . . . .234 CONTRIBUTORS Chapter 1: Anatomy and Physiology Chapter 6: Problems with the Gingiva John R. Lewis, VMD, FAVD, DAVDC Linda DeBowes DVM, MS, DACVIM, DAVDC Assistant Professor of Dentistry and Oral Surgery Shoreline Veterinary Dental Clinic, Seattle, USA Matthew J. Ryan Veterinary Hospital of the Chapter 7: Pathologies of the Oral Mucosa University of Pennsylvania, Philadelphia, USA Brook A. Niemiec DVM, DAVDC, FAVD Alexander M Reiter, Dipl Tzt, Dr med vet, Southern California Veterinary Dental Specialties, DAVDC, EVDC San Diego, USA Assistant Professor of Dentistry and Oral Surgery Chapter 8: Problems with Muscles, Bones, and Matthew J. Ryan Veterinary Hospital of the Joints University of Pennsylvania, Philadelphia, USA Kendall G. Taney, DVM, DAVDC, FAVD Chapter 2: Oral Examination Center for Veterinary Dentistry and Oral Surgery, Lee Jane Huffman, DVM, DAVDC Gaithersburg, MD, USA Pet Emergency Clinics and Specialty Mark M. Smith, VMD, DACVS, DAVDC Hospital,Ventura and Thousand Oaks, USA Center for Veterinary Dentistry and Oral Surgery, This chapter is dedicated with all my love to Gaithersburg, MD, USA Rebeckah, Nonatime, and my wee ‘Monsieur’. Chapter 9: Malignant Oral Neoplasia Chapter 3: Veterinary Dental Radiology Ravinder S. Dhaliwal DVM, MS, DACVIM, Brook A. Niemiec DVM, DAVDC, FAVD DABVP vetdentalrad.com Pet Care Veterinary Hospital, Santa Rosa, CA, USA Chapter 4: Pathology in the Pediatric Patient This chapter is dedicated to my two little angels, Brook A. Niemiec DVM, DAVDC, FAVD Siona and Nikita, Southern California Veterinary Dental Specialties, who have given a new perspective to my life. San Diego, USA Chapter 10: Pathologies of the Salivary System Chapter 5: Pathologies of the Dental Hard Tissues Brook A. Niemiec DVM, DAVDC, FAVD Gregg DuPont DVM, DAVDC Southern California Veterinary Dental Specialties, Shoreline Veterinary Dental Clinic, Seattle, USA San Diego, USA FOREWORD 6 Veterinary dentistry has exploded as a discipline within veterinary medicine over the past 20+ years, primarily due to the tireless efforts of those clinicians in the 1970s and early 1980s who took an often overlooked area of the patient, and turned it into a focus of major significance. Thanks to these pioneers in veterinary dentistry, many of us found our calling within veterinary medicine and provide a valuable service to animals throughout the world. In the early days of veterinary dentistry, those who had a special interest in dentistry would gather together and discuss conditions and treatments they had found to be particularly helpful or successful. Out of these meetings rose the organization of the American Veterinary Dental Society and the Veterinary Dental Forum. The Veterinary Dental Forum has grown to an annual meeting of nearly 1000 participants, a far cry from the early days of getting together around a cold beverage to talk about your most challenging/rewarding cases! Also blossoming out of the efforts of these pioneers has come the Journal of Veterinary Dentistry, a quarterly publication that is currently recognized internationally as the journal of record for veterinary dentistry. All these efforts were to help educate veterinarians about veterinary dentistry and to elevate the practice of veterinary medicine in general. Though many aspects of veterinary dentistry are continuously evolving, one constant is the clinical practicality of veterinary dentistry. This is reflected in the organization and thought process throughout this book. Dr. Niemiec does an excellent job presenting many dental conditions from a very practical standpoint. Beginning with the initial oral examination, through the diagnostic procedures, such as dental radiography, Dr. Niemiec provides pragmatic tips along the way. Reading this text is similar to the way practitioners think through diagnostic challenges within their own practices. From the early chapters that focus on the normal oral/dental anatomy through the oral examination and diagnostics for all areas of the mouth, this text is a valuable reference for both the general practitioner and the seasoned veterinary dentist. Those of us, like Dr. Niemiec, who have walked in the footsteps of those pioneers of the early days of veterinary dentistry, can only hope to carry on the tradition of educating others in our quest to relieve unnecessary patient suffering. This book is an excellent tribute to those practitioners. With gratitude and thanks, Michael Peak, DVM, DAVDC Immediate Past-President, American Veterinary Dental College PREFACE 7 This book is designed to be a quick reference for practitioners to identify the common oral pathologies in the dog and cat. All pathologies are demonstrated by typical photographic and, in some cases, radiographic examples. Along with the graphic examples is a concise but complete and current description of the pathology. The description includes etiology, pathogenesis, clinical features, differential diagnoses, diagnostic tests, and treatment/management. Each topic is then summarized in easy-to-read key points. This format will make identification and initial therapy of oral diseases much more efficient. The first three chapters set a foundation for assessing and diagnosing oral pathology. Chapter one is a review of oral anatomy and physiology. In the style of the book, this is supported with numerous full color images. Chapter two presents a stepwise guide on how to perform a proper oral examination. These techniques will allow practitioners to find the subtle pathologies listed within the book. Finally, dental radiology is presented. The first part of chapter three discusses proper techniques for obtaining quality dental radiographs, and the latter part discusses proper diagnosis of dental radiographs with high-quality digital images. Following this introduction, the book is presented by anatomic areas, to ease identification of unknown pathology. These areas include problems with the: teeth; gingiva; oral mucosa; bones, muscles, and joints; and salivary glands. Individual chapters have been created for pediatric oral/dental problems and malignant oral neoplasia. These unique topics are presented separately from the anatomical chapters to decrease time spent scanning the other chapters. Using this efficient format, if a patient under about 9 months is presented, the practitioner should only have to go beyond the pediatric chapter on rare occasions. Furthermore, if presented with a novel pathology, the practitioner may not know the name of the disease process, thereby making an index much less useful. By directly targeting the chapter which deals with that area of the mouth (for example the lesion is on the tooth), the practitioner can quickly scan just a few pathologies until he/she finds a picture that looks like the lesion in question. Then, in just a few minutes, the reader can learn all about the disease process, including what tests should be run to confirm the diagnosis as well as how best to manage it. Even experienced practitioners will benefit from the cutting edge information in this book. In addition, the succinct and practical style of this volume lends itself to be a client-friendly education tool. The veterinarian can use this peer-reviewed book to back up their management recommendations. This is critically important in veterinary dentistry, as most pathologies do not have obvious clinical signs that owners recognize (fractured teeth for example). The prudent practitioner will encourage clients to read the brief description of their pet’s particular pathology, thus improving client compliance with treatment recommendations. Since dental disease is present in almost all veterinary patients, I would consider having a copy in each exam room. This will aid all dental related discussions. This book makes numerous treatment recommendations, but it is not a technical manual. For those practitioners interested in improving their technical skills, I recommend Veterinary Dental Techniques, 3rd edn, by Holmstrom SE, Frost P, and Eisner ER (eds), Saunders, 2004. However, these techniques (including dental radiology) are best learned through hands-on training at wetlabs. For a list of my wetlabs in San Diego, visit www.sdvdtc.com. Brook A. Niemiec, DVM,DAVDC, FAVD ABBREVIATIONS 8 AI amelogenesis imperfecta MGM/ APD air-polishing device MGL mucogingival margin/line BPAB black pigmented anaerobic bacteria MM masticatory myositis CBC complete blood count MRI magnetic resonance imaging CEJ cementoenamel junction MTA mineral trioxide aggregate CI calculus index NSAID nonsteroidal anti-inflammatory drug CK creatine kinase OAF oroantral fistula COC calcifying odontogenic cyst OSA osteosarcoma CT computed tomography PDL periodontal ligament CUPS chronic ulcerative paradental stomatitis PEG percutaneous endoscopic gastrostomy DI dentinogenesis imperfecta PI plaque index DR digital radiograph PTH parathyroid hormone EGC eosinophilic granuloma complex RT-PCR reverse transcriptase polymerase chain EMG electromyography reaction FCV feline calicivirus SCC squamous cell carcinoma FE furcation exposure SE extrinsic staining FeLV feline leukemia virus SI intrinsic staining FIV feline immunodeficiency virus SLE systemic lupus erythematosus FNA fine-needle aspiration SLOB same-lingual/opposite-buccal FSA fibrosarcoma SRP scaling and root planing GI gingival index TEN toxic epidermal necrolysis HIV human immunodeficiency virus TNF tumor necrosis factor IL-1 interleukin-1 TVT transmissible venereal tumor IVIG intravenous immunoglobulin VOHC Veterinary Oral Health Care Council LEO lesions of endodontic origin CHAPTER 1 9 Anatomy and Physiology John R. Lewis and Alexander M. Reiter • Canine dental anatomy • Feline dental anatomy • Rodent and lagomorph dental anatomy • Dental anatomical terminology • Tooth development • Enamel, dentin, and pulp • Periodontium • Bones of the face and jaws • Muscles, cheeks, and lips • Neurovascular structures • Joints of the head • Hard and soft palates • Tongue • Salivary glands • Lymph nodes and tonsils