History and Physical Examination Findings
An 8-year-old 57-kg (12.5-lb) spayed female Miniature Poodle cross was referred to a veterinary dental facility for a comprehensive oral health assessment and treatment. The patient was referred following a routine periodontal treatment by the primary care veterinarian; at that time, severe periodontal disease was noted at the left maxillary first molar and the right mandibular canine teeth.
Preoperative physical examination revealed a rectal temperature of 38.2°C (100.8°F) and heart rate of 120 beats/min; the dog was panting. The remaining physical examination findings were unremarkable. Results of a CBC indicated lymphopenia (660 cells/μL; reference range, 1,060 to 4,950 cells/μL) with no other abnormalities, and serum biochemical analysis indicated a high triglyceride concentration (1,263 mg/dL; reference range, 20 to 150 mg/dL), but the results (including canine pancreas-specific lipase and thyroxine concentrations) were otherwise within the respective reference ranges. No abnormalities were detected on thoracic radiographs. The patient was deemed a suitable candidate for anesthesia.
A complete oral examination and charting were performed with the patient under general anesthesia. Clinically relevant abnormalities included increased mobility1 of the right and left maxillary first molar, right mandibular canine and third molar, and left mandibular third molar teeth. Probing depths of ≥ 4 mm were found at the right and left maxillary fourth premolar and right maxillary first molar teeth. Apparently missing teeth were noted at the sites of the right and left maxillary first incisor, left maxillary first and second premolar, and right maxillary second premolar teeth. The right mandibular first, second, and third incisor; left mandibular first incisor; right mandibular first and second premolar; and left mandibular second premolar teeth also appeared to be missing. Stage 1 furcation involvement1 was found at the right maxillary fourth premolar, right maxillary first molar, and left maxillary fourth premolar teeth. Full-mouth dental radiographs2 were obtained. A lateral view of the right mandibular canine tooth and an occlusal view of the rostral aspects of the mandibles are provided (Figure 1).
Right lateral radiographic view of the right mandibular canine tooth (A) and occlusal view of the rostral aspects of the mandibles (B) of an 8-year-old Miniature Poodle cross that was referred for complete oral evaluation and treatment after periodontal disease was found at the left maxillary first molar and right mandibular canine teeth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Right lateral radiographic view of the right mandibular canine tooth (A) and occlusal view of the rostral aspects of the mandibles (B) of an 8-year-old Miniature Poodle cross that was referred for complete oral evaluation and treatment after periodontal disease was found at the left maxillary first molar and right mandibular canine teeth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Right lateral radiographic view of the right mandibular canine tooth (A) and occlusal view of the rostral aspects of the mandibles (B) of an 8-year-old Miniature Poodle cross that was referred for complete oral evaluation and treatment after periodontal disease was found at the left maxillary first molar and right mandibular canine teeth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Determine whether additional studies are required, or make your diagnosis, then turn the page →
Diagnostic Imaging Findings and Interpretation
Radiopaque suspected foreign material (approx 5 × 2 × 1.3 mm) was found encircling the right mandibular canine tooth just apical to the cementoenamel junction (Figure 2). An area of horizontal bone loss was found apical to the suspected foreign material, and a mildly sclerotic alveolar margin was detected approximately 2 mm from the most apical aspect of the suspected foreign material. The sclerotic alveolar margin and approximately 70% horizontal periodontal bone loss at the right mandibular canine tooth were likely secondary to presence of the suspected foreign material.
Same lateral (A) and occlusal (B) radiographic views as in Figure 1. Radiopaque suspected foreign material is seen encircling the right mandibular canine tooth just apical to the cementoenamel junction (arrows). An area of horizontal bone loss is evident apical to the suspected foreign material, and a mildly sclerotic alveolar margin (arrowheads) is present approximately 2 mm from the most apical aspect of the suspected foreign material.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Same lateral (A) and occlusal (B) radiographic views as in Figure 1. Radiopaque suspected foreign material is seen encircling the right mandibular canine tooth just apical to the cementoenamel junction (arrows). An area of horizontal bone loss is evident apical to the suspected foreign material, and a mildly sclerotic alveolar margin (arrowheads) is present approximately 2 mm from the most apical aspect of the suspected foreign material.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Same lateral (A) and occlusal (B) radiographic views as in Figure 1. Radiopaque suspected foreign material is seen encircling the right mandibular canine tooth just apical to the cementoenamel junction (arrows). An area of horizontal bone loss is evident apical to the suspected foreign material, and a mildly sclerotic alveolar margin (arrowheads) is present approximately 2 mm from the most apical aspect of the suspected foreign material.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
All teeth that were identified as missing during the oral examination were confirmed to be absent, except that retained roots of the left maxillary second premolar tooth were present (not shown). Periodontal disease for each tooth was staged according to the classification system described by Wolf et al.3 Stage 4 periodontal disease was found at the right mandibular canine tooth. Stage 3 periodontal disease was found at the right maxillary first and third premolar, left maxillary first molar, left mandibular third molar, and right mandibular third molar teeth. Stage 2 periodontal disease was found at the right and left maxillary fourth premolar, right maxillary first molar, and left mandibular second and third incisor teeth.
Treatment and Outcome
Following assessment of the full-mouth dental radiographs, the right mandibular canine tooth was reexamined. During the initial oral examination and charting, the foreign material had not been detected because of its similar color and close relationship to the gingival margin (Figure 3). What was initially thought of as the gingival sulcus at the right mandibular canine tooth had a depth of 1 to 2 mm buccally and distally and 5 mm lingually and mesially; however, the probe had only reached the coronal aspect of the foreign material. On reexamination, the probe was walked off the foreign material, and probing depths of 9 mm buccally and distally and 12 mm lingually and mesially were found.
Preoperative photographs of the right mandibular canine tooth of the same dog as in Figure 1. A—The foreign material that was identified radiographically at the gingival margin is difficult to detect against the darkly pigmented gingiva. B—A periodontal probe is placed between the foreign material and the buccal gingiva at the right mandibular canine tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Preoperative photographs of the right mandibular canine tooth of the same dog as in Figure 1. A—The foreign material that was identified radiographically at the gingival margin is difficult to detect against the darkly pigmented gingiva. B—A periodontal probe is placed between the foreign material and the buccal gingiva at the right mandibular canine tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Preoperative photographs of the right mandibular canine tooth of the same dog as in Figure 1. A—The foreign material that was identified radiographically at the gingival margin is difficult to detect against the darkly pigmented gingiva. B—A periodontal probe is placed between the foreign material and the buccal gingiva at the right mandibular canine tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
The owner was advised that extraction of the right mandibular canine tooth was needed because of severe periodontal disease, which was likely secondary to the foreign material. Extraction of the retained roots of the left maxillary second premolar tooth was offered, and extraction of the right maxillary first and third premolar, left maxillary first molar, left mandibular third molar, and right mandibular third molar teeth was recommended because of stage 3 periodontal disease.
Left and right infraorbital and inferior alveolar nerve blocks were performed with a mixture of bupivacaine hydrochloride (5 mg/mL) and epinephrine (1:200,000), with 0.2 mL (1 mg of bupivacaine) administered for each block. All teeth were ultrasonically scaled supragingivally and subgingivally, followed by polishing with a combination of flour pumice and 0.12% chlorhexidine gluconate solution. The right maxillary first and third premolar, left maxillary first molar, right mandibular canine, and right and left mandibular third molar teeth, as well as the retained roots of the left maxillary second premolar tooth, were extracted; complete removal was confirmed radiographically. On extraction of the right mandibular canine tooth, the foreign material was found to be a black elastic band (Figure 4). All flaps were closed with fine absorbable suture in a simple interrupted pattern. Recovery from anesthesia was uneventful. The patient was discharged from the hospital, and the client was instructed to administer tramadol hydrochloride (3 mg/kg [1.36 mg/lb], PO, q 8 h) for 5 days' duration. The client was instructed to feed only soft food until the recheck examination. At the follow-up examination 2 weeks later, the extraction sites were considered to be appropriately healed. The client was instructed to return the dog to its normal diet and activities and to start a daily home-care regimen that included brushing the teeth. Recommendations for routine periodontal treatment, including a complete oral examination and radiography of the patient under general anesthesia 6 months after the follow-up visit, were made to monitor the remaining teeth for possible progression of periodontitis.
Photograph of the right mandibular canine tooth following extraction. The elastic band was left in place to show its location and size relative to the tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Photograph of the right mandibular canine tooth following extraction. The elastic band was left in place to show its location and size relative to the tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Photograph of the right mandibular canine tooth following extraction. The elastic band was left in place to show its location and size relative to the tooth.
Citation: Journal of the American Veterinary Medical Association 250, 12; 10.2460/javma.250.12.1373
Comments
As part of a complete oral examination and dental charting, the patient's mouth should be examined for the presence of foreign material. During the initial oral examination and charting for the dog of this report, the foreign material was not identified, and it was later discovered on examination of dental radiographs. The secure nature of the elastic band foreign body, positioned just at the gingival margin, and its black color alongside the dog's darkly pigmented gingiva had made it difficult to detect. The elastic band was moderately radiopaque on intraoral radiographs. Without dental radiography, this foreign body might have been overlooked as it had been by the referring veterinarian and during the authors' initial examination. The nature of the elastic band was not determined, and the history provided no indication of its origin.
Subgingival elastic bands were first noted in 1870 to cause destruction of periodontal ligaments and the loss of teeth in an 11-year-old child.4 A literature search revealed no reports of similar cases involving elastic bands in veterinary patients. However, in human patients, incorrect direct application of orthodontic elastic bands has led to ≥ 25 clinical reports of elastic band migration with periodontal ligament destruction and, frequently, tooth loss. Historically, elastic bands were intentionally used to extract teeth in people with coagulation abnormalities5 and in patients with a high risk of osteonecrosis because of bisphosphonate treatment6; however, this method fell out of favor owing to the potential for several complications.
The case described in the present report illustrates the importance of full-mouth dental radiographs. Although a complete oral examination with periodontal probing had been performed, the elastic band was not discovered until dental radiographs were examined. Without appropriate dental radiographs, this foreign body could have continued to be overlooked and led to worsening periodontal disease, infection, and bone loss, resulting in discomfort to the patient and possibly leading to pathological mandibular fracture.7,8
References
1 American Veterinary Dental College. Nomenclature: periodontal disease. Available at www.avdc.org/Nomenclature/Nomen-Perio.html#periofm. Accessed Jun 2, 2016.
2 Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res 1998; 59: 686–691.
3 Wolf HF, Rateitschak EM, Rateitschak KH, et al. Indices & epidemiology. In: Color atlas of dental medicine: periodontology. 3rd ed. Stuttgart, Germany: Georg Thieme Verlag, 2005; 67–76.
4 McQuillen JH. Care in the use of India rubber rings (edit). Dent Cosmos 1870; 12: 429.
5 Spouge JD. Hemostasis in dentistry, with special reference to hemocoagulation. II. Principles underlying clinical hemostatic practices in normal patients. Oral Surg Oral Med Oral Pathol 1964; 18: 583–592.
6 Regev E, Lustmann J, Nashef R. Atraumatic teeth extraction on bisphosphonate-treated patients. J Oral Maxillofac Surg 2008; 66: 1157–1161.
7 Mulligan TW, Aller MS, Williams CA. Trauma. In: Atlas of canine and feline dental radiology. Trenton, NJ: Veterinary Learning Systems, 1998; 176–183.
8 Niemiec BA. Local and regional consequences of periodontal disease. In: Veterinary periodontology. Ames, Iowa: Wiley-Black well, 2013; 71–75.
