Dental Diseases

Periodontal Disease

Gingivitis and periodontal disease remain among the most common diseases of companion animals affecting the majority of adults promoted by pet rejection of, or lack of, daily tooth-brushing efforts from their owners, and exacerbated by many factors such as individual poor defences against oral bacteria, malocclusion, etc. Chew treats misleadingly marketed to pet owners as effective prevention and control of oral disease distract pet owners from embracing the need for daily tooth brushing.

Gingivitis can lead to periodontal bone loss, often often by the time dental examination and radiographs are done because if bone loss is occurring it may be hidden by the gums and perhaps calculus and pus. Un-treated, over time bone loss progresses, and deeper pockets lead to a change in bacterial flora to more bone-damaging anaerobes. The result is deterioration of general health and comfort, and eventual tooth loss.

With the help of a thorough oral examination, pocket probing and intra-oral radiographs under anesthesia, each tooth can be assessed and treated accordingly.

 

Stomatitis

Predominantly among cats, stomatitis is a terribly painful chronic and progressive disease of cats. The cause is not fully understood and is likely multifactorial, but the cat’s exuberant reaction to oral plaque bacteria may be a key. Medications are often of little help and for affected cats. Full mouth extraction is often the key to controlling the illness permanently. Some cats may need to be on long term medication afterwards, but many do not.

 

Malocclusion

Teeth that don’t occlude properly set the patient up for trouble from the start such as:

  • Inability to fully close the mouth

  • Chronic pain from teeth intruding into soft tissue of the opposing jaw

  • Lack of normal tooth self-cleaning from teeth of the opposing jaw promoting plaque retention and premature periodontal disease

 

Missing Teeth & Dentigerous Cyst

Dogs that are missing teeth means radiographs are indicated- perhaps they are truly missing or perhaps they are impacted, meaning the crown of the tooth failed to break through the gingiva into the mouth. Mandibular 1st premolar and mandibular 3rd molar teeth are most commonly represented but other teeth such as canine teeth can be involved.

An impacted tooth will sometimes develop a slowly-expanding cyst around the tooth inside the jawbone called a “dentigerous cyst”. These cysts can become very large and cause extensive destruction of the jaw leading to loss of adjacent teeth and possibly jaw fracture.

Impacted teeth are best extracted before a cyst develops. If a cyst is already present, extraction of the tooth and removal of the cyst lining is necessary.

 

Persistent Primary Teeth

Particularly in dogs, failure to shed primary teeth before the adult counterpart erupts is a common problem that can have significant consequences. There should never be two teeth occupying the same space at the same time. The primary tooth should be lost before the adult tooth erupts.

In the case of canine teeth, the presence of the primary tooth forces the adult canine tooth to erupt in an unfavourable position, possibly causing a malocclusion problem. The adult tooth usually comes in tightly against and usually distal to the primary tooth, leaving no space for a protective ring of gingiva between the two. Food and hair get wedged between teeth, gingivitis sets in very early and periodontal disease will eventually claim both teeth. Extraction of the primary tooth early in life is necessary.

Persistent primary incisors, premolars and sometimes molars are also found; if an adult counterpart is present, the primary tooth needs to be extracted.

 

Non-Vital Teeth

Brown, pink, or purple coloured teeth indicated that in the past there has been a significant hemorrhage of the pulp inside of the tooth, such as through a concussion or blunt trauma. Dr. Hale in 2001 published a study of discoloured teeth showing a 92% chance that the tooth affected was dead. Clinically this is a common finding with canine and incisor teeth. Radiographs may show periapical changes indicative of chronic pain and inflammation but may be falsely negative if changes are early.

Teeth have a robust blood supply, and the body sees dead pulp inside a dead tooth, like any other dead tissue, like a foreign material that needs to be removed. In the case of dental pulp, that often leads to a chronic, often sterile inflammation. It won’t go away until the pulp through root canal treatment, or the entire tooth through extraction, is completely removed.

 

Fractured Teeth

A fractured teeth with exposed pulp chamber produces:

  • Acute pain when the tooth breaks. Dental pup is richly innervated, and it hurts a lot when exposed to air, liquids, or direct touch

  • Subacute pain afterwards may linger weeks or months as the exposed pulp tissue soon becomes chronically inflamed

  • Chronic pain as bacteria ingress through the pulp system and leach out into the periapical area causing inflammation

  • Chronic pain after the pulp dies, as it usually does, from chronic inflammation, or abscess if bacteria are involved, in the periapical area.

The symptoms of a crown fracture with pulp exposure may start with a sudden bleeding tooth with an aggravated dog or cat. As the patient gets used to the pain, symptoms are usually absent. After weeks or months, periapical inflammation may advance all the way through the periapical bone and extend into the soft tissues of the face where it becomes more obvious to us through visible facial swelling +/- a draining tract through the skin or into the mouth. This is commonly seen with fractured maxillary 4th premolar teeth that develop a swelling and/or drainage below the eye.

It is important to note that periapical granulomas that become visible in soft tissues in the mouth on or the face have likely been painful for months or years beforehand. Chronic pain and suffering happens quietly right before our eyes.  All fractured teeth need treatment regardless of whether symptoms of pain are perceived by us or not. The sequelae of pulp exposure are predictable and inevitable. Neglect of fractured teeth often happens- like other chronic pain there is no overt yelping or vocalizing; just a quiet dog or cat that seems to be acting older but still happy to see you; perhaps he or she goes to bed earlier at night than in the past- that is what pain often looks like.  Please don’t “wait and see” on a fractured tooth because you will likely continue to wait and see nothing while the patient suffers in pain quietly.

Fractured teeth with pulp exposure demand either extraction or root canal treatment.

 

Enamel Chips

A less extensive trauma than a fracture with pulp exposure is a patch of missing enamel. The enamel is a thin layer of impervious veneer that protects the intensely innervated and biologically active living part of the tooth. Beneath the enamel lies the dentin which makes up the majority of the tooth structure. Dentin is spongelike with tiny tubules or holes leading to the pulp in the middle of the tooth; there are an incredible 60,000 tubules per square mm and a nerve ending extending from the pulp occupies each tubule.

The result of a deep enamel chip that approaches the pulp chamber is:

  • Acute pain. A patch of exposed nerve endings hurts even if it looks minor to us

  • Chronic pain as bacteria ingress into the dentinal tubules towards and sometimes into the pulp, and produce similar consequences to a fractured tooth due to chronic inflammation

Missing enamel will never come back but the tooth sometimes can “heal” itself from superficial knicks and chips by producing reparative dentin in place of enamel which appears pale yellow vs white enamel. Deeper chips and slabs that approach the pulp chamber need to have a sealant bonded to the dentin to protect the exposed tubules. Radiographs are indicated in any case to ensure the tooth is vital.

The signs of pain from missing enamel: generally, none. Chronic pain is usually silent.

 

Gingival Hyperplasia & Gingivectomy

Boxers often have a genetic predisposition to gingival hyperplasia but it can occur in other individuals caused by medication side effects or other causes. Gingival hyperplasia leads to “pseudo pockets”- areas where pockets form above the gumline due to excessive new gum tissue- this tissue can be painful during chewing or if it gets in the way of opposing teeth; the pseudo pockets also provide an area where food and hair are retained promoting true periodontal pockets and eventual compromise of tooth health.

In some cases, surgical resection of exuberant excess gum tissue is necessary.