Diagnostic Imaging in Veterinary Dental Practice

Sharon L. Hoffman 1Veterinary Dental Consulting, Jacksonville, FL 32226.

Search for other papers by Sharon L. Hoffman in
Current site
Google Scholar
PubMed
Close
 DVM
and
Susan K. Ridinger 2VCA Briarcliff Animal Hospital, Jacksonville, FL 32216.

Search for other papers by Susan K. Ridinger in
Current site
Google Scholar
PubMed
Close
 DVM

History and Physical Examination Findings

A 9-year-old 14-kg (30.8-lb) spayed female mixed-breed dog was presented to a veterinary hospital for oral examination, dental radiography, and routine periodontal treatment. The dog had undergone complete annual physical and oral examinations during 2 consecutive years prior to this visit. At the initial visit, serum biochemical analysis revealed hypercalcemia and hypophosphatemia (Appendix). Other examination and clinicopathologic test results were unremarkable. Cervical ultrasonography revealed a right parathyroid gland nodule. Thoracic and abdominal radiography and abdominal ultrasonography findings were unremarkable. A diagnosis of primary hyperparathyroidism was made; referral for parathyroidectomy was recommended but declined by the owner. Oral examination revealed full dentition, mild mandibular mesioclusion1 with attrition of the mesial aspects of the mandibular canine teeth and distal aspects of the maxillary third incisor teeth, and abrasion on the distal aspects of the mandibular canine teeth. There was mild mobility (0.2 to 0.5 mm [degree I])2 of the mandibular incisor teeth, generalized grade 1 gingivitis,2 and supragingival calculus, with no abnormal probing depths detected. Full-mouth radiography revealed fused roots of the left mandibular second premolar tooth; pulp cavity obliteration3 of the left and right mandibular first, second, and third premolar teeth; and horizontal bone loss (25% to 50%) affecting the mandibular incisor teeth. The teeth were cleaned and polished.

One year later, the dog had developed urinary incontinence. Temporal muscle atrophy and weight loss were observed, and serum biochemical analysis revealed increased total calcium concentration (Appendix). Generalized gingivitis and minimal supragingival calculus were observed on oral examination; full-mouth radiography and periodontal evaluation revealed no changes from the previous year. Routine periodontal treatment was performed. Phenylpropanolaminea (1.6 mg/kg [0.7 mg/lb], PO, q 12 h) was prescribed for the urinary incontinence after ruling out urinary tract infection.

At the third annual examination, pertinent history included inappetence and continued weight loss; urinary incontinence was controlled with phenylpropanolamine. Temporal muscle atrophy and signs of hip joint pain were present. Serum total and ionized calcium concentrations were high, and creatinine concentration was near the upper limit of the reference range (Appendix). Chronic renal disease (International Renal Interest Society [IRIS] stage 2)4 was diagnosed. Oral examination revealed generalized grade 1 gingivitis,2 supragingival calculus, and normal probing depths. Full-mouth radiographs were obtained. Selected images are provided (Figure 1)

Figure 1—
Figure 1—

Selected bisecting angle (A and B) and parallel (C and D) radiographic views of the teeth of a 9-year-old mixed-breed dog that was presented for routine oral examination and dental cleaning. A—Right maxillary second and first molar teeth, fourth premolar tooth, and third premolar tooth distal root. B—Left maxillary second premolar tooth distal root, third and fourth premolar teeth, and first molar tooth. C—Right mandibular second and first molar teeth. D—Left mandibular fourth premolar tooth distal root, first molar tooth, and roots of the second molar tooth.

Citation: Journal of the American Veterinary Medical Association 256, 10; 10.2460/javma.256.10.1105

Determine whether additional studies are required, or make your diagnosis, then turn the page →

Diagnostic Imaging Findings and Interpretation

Dental radiography revealed vertical alveolar bone loss with furcation involvement affecting premolar and molar teeth in all 4 quadrants of the mouth (Figure 2) Loss of the lamina dura and loss of the trabecular bone pattern in the interradicular and interalveolar septa were observed. The alveolar margin was ill-defined or thin in the interdental areas. Vertical bone loss extended periapically around the roots of the maxillary third and fourth premolar and the mandibular first and second molar teeth. Radiographic evidence of vertical bone loss and periapical lucencies, which was not detected in the previous examinations, mimicked combined periodontal-endodontal lesions.5,6 However, there was no evidence on oral examination for a cause of endodontal disease, such as dental fracture or abrasion, that would have resulted in pulp necrosis of these teeth. In addition, the pulp cavities were bilaterally symmetric in shape and size, which would indicate that all teeth were concurrently nonvital or were still vital. There were no abnormal probing depths, premolar or molar tooth mobility, or other findings that would support the presence of periodontal or endodontal disease.

Figure 2—
Figure 2—

Same radiographic images as in Figure 1. Absence of the lamina dura and widening of periodontal ligament space around tooth roots (A through D; thin arrows), loss of the trabecular bone pattern in interradicular and interalveolar septa (A, B, and D; thick arrows), and poorly defined alveolar margins (B and D; forked thick arrow) are evident.

Citation: Journal of the American Veterinary Medical Association 256, 10; 10.2460/javma.256.10.1105

The history, clinical signs, clinicopathologic findings, and ultrasonographic detection of a parathyroid nodule were consistent with the diagnosis of primary hyperparathyroidism. In the absence of periodontal attachment loss and with no obvious causes for endodontal disease found, the radiographic findings were consistent with oral manifestations of hyperparathyroidism.7–9

Treatment and Outcome

The changes observed on dental radiographs at the third annual visit, compared with results in the previous years, led the owner to pursue referral to a veterinary surgeon for the dog to have parathyroidectomy. Calcitriolb (0.04 μg/kg [0.02 μg/lb], PO, q 24 h beginning 5 days prior to surgery) was prescribed by the surgeon as prophylaxis against postoperative hypocalcemia. A single nodule was found intraoperatively on the right cranial parathyroid gland. Extracapsular excision of the right cranial paraythyroid gland with partial excision of the right thyroid gland was performed. There were no visible or palpable nodules found on the left parathyroid glands. Histologic examination of the excised tissue revealed a parathyroid gland adenoma. One week after surgery, serum ionized calcium concentration was low (1.07 mmol/L) and parathyroid hormone concentration remained high (32.2 pmol/L), with phosphorus concentration within the refence range and BUN concentration slightly high (32 mg/dL; reference range, 6 to 31 mg/dL). One month after surgery, the patient was reported to have an improved appetite and increased energy. The serum ionized calcium concentration was slightly high (1.44 mmol/L), and the calcitriol treatment was discontinued.

The patient was returned to the hospital for a fourth annual oral examination, dental radiography, and periodontal evaluation 9 months after the parathyroidectomy was performed. There was partial improvement in temporal muscle atrophy, and the dog was being fed therapeutic dietsc,d for management of renal disease. Weight gain (from 14 to 14.8 kg [30.8 to 32.6 lb]), improved body condition score (from 3/9 to 5/9),10 and normalization of serum total calcium concentration (11.3 mg/dL) were noted. Serum ionized calcium concentration was mildly high (1.48 mmol/L), and serum creatinine concentration (1.8 mg/dL) still reflected IRIS stage 2 chronic renal disease.4 The patient's serum parathyroid hormone concentration had increased substantially (163.8 pmol/L), and cervical and abdominal ultrasonography were recommended to rule out the presence of new parathyroid gland nodules but were declined by the owner. Oral examination results were similar to those of the previous visit. Full-mouth radiography revealed restored trabecular bone patterns in the interradicular and interalveolar septa; lamina dura was present in most sites, and alveolar bone margins were more defined in most sites, compared with the previous findings (Figure 3) There was widening of the periodontal ligament space at the distal root of the first molar tooth and vertical bone loss at the distal root of the fourth premolar tooth. There was an ill-defined alveolar bone margin between the first and second left mandibular molar teeth. There was a new irregular radiopacity at the mesial midroot of the left mandibular first molar tooth and an irregular radiopacity at the mesial aspect of the tooth apex. The differential diagnoses for the opacities on this tooth root included osteosclerosis and focal sclerosing osteitis.11

Figure 3—
Figure 3—

Selected bisecting angle (A and B) and parallel (C and D) radiographic views of the teeth of the dog in Figure 1 obtained 9 months after right cranial parathyroidectomy. A—Right maxillary second and first molar teeth and fourth premolar tooth. The trabecular bone pattern and lamina dura are present in the periradicular and interradicular areas of the fourth premolar tooth. B—Left maxillary second and third premolar teeth and mesial roots of the fourth premolar tooth. The trabecular bone pattern is evident in the interradicular and interalveolar septa of the premolar teeth. Lamina dura is present, and the alveolar margin is defined between the third and fourth premolar teeth at the level of the cementoenamel junctions. C—Right mandibular second molar tooth roots, first molar tooth, and fourth premolar tooth (distal aspect). Lamina dura is present in most areas. There is widening of the periodontal ligament space (thin arrow) at the coronal aspect of the distal root of the first molar tooth and vertical bone loss between the fourth premolar and first molar teeth (dotted arrow). D—Left mandibular fourth premolar tooth (distal root), first molar tooth, and mesial root of the second molar tooth. Lamina dura is present at most of the root surfaces except the mesial aspect of the mesial root of the first molar tooth; the trabecular bone pattern at this site is irregular, with an area of radiopacity at the apex of the mesial root (arrowhead). There is an irregular margin on the mesial aspect of the mesial midroot of the first molar tooth (caret). The alveolar margin is ill-defined between the first and second molar teeth (forked arrow).

Citation: Journal of the American Veterinary Medical Association 256, 10; 10.2460/javma.256.10.1105

Fifteen months after parathyroidectomy, the dog weighed 19.1 kg (42 lb) and had a body condition score of 7 of 9.10 The dog's serum parathyroid hormone concentration (59.9 pmol/L) had decreased from the previous measurement but remained greater than the upper reference limit; the serum ionized calcium concentration was high (1.55 mmol/L), with phosphorus concentration within the reference range and serum creatinine concentration of 1.7 mg/dL (reflecting IRIS stage 2 chronic renal disease4). Six months later (21 months after parathyroidectomy), the patient's serum parathyroid hormone concentration was still high (19.1 pmol/L) but had continued to decrease; serum ionized calcium concentration remained high (1.54 mmol/L), with phosphorus concentration within the reference range and creatinine concentration of 1.3 mg/dL (reflecting IRIS stage 1 chronic renal disease4).

Comments

The case described here demonstrated the value of obtaining annual dental radiographs and illustrated the importance of interpreting dental radiographic findings in the light of the patient's systemic health and oral examination findings. It is essential to differentiate between primary oral diseases and those secondary to systemic disease in treatment planning. In people, bony changes in the jaws are part of the systemic manifestation of primary hyperparathyroidism.7,8 Common findings include a ground-glass appearance of the trabecular bone and loss of the lamina dura.7,8 The oral radiographic findings associated with primary hyperparathyroidism may mimic combined periodontal-endodontal radiographic lesions, as both conditions are characterized by alveolar bone resorption (loss of lamina dura on radiographs).5–8 In a cross-sectional case-control study8 of human patients, people with primary hyperparathyroidism had greater signs of bone loss on dental radiographs than did people without hyperparathyroidism but had no alternations in periodontal variables such as bleeding on probing, furcation involvement, or soft tissue attachment loss. This suggests that primary hyperparathyroidism impacts the oral cavity in people but that reduced bone density may not predispose to alterations in the soft tissue attachment apparatus that are consistent with periodontitis. The intraoral examination and radiographic findings for the dog of the present report were in agreement with those described for people with primary hyperparathyroidism. No attachment loss, abnormal probing depths, or mobility of the premolar or molar teeth was found in association with the described radiographic changes, and evidence of dental trauma that could cause loss of tooth vitality and predispose to radiographic endodontal lesions was lacking.

Clinically, dogs with primary hyperparathyroidism often appear healthy to owners and veterinarians. Clinical signs may be absent, vague, or mild.12 However, signs such as urinary incontinence, polyuria, polydipsia, listlessness, inappetence, muscle wasting, emesis, urinary blockage, urolithiasis, or signs related to urinary tract infection can develop.12 Dogs with secondary hyperparathyroidism resulting from chronic renal failure may have clinical signs such as uremic ulcers of the oral mucosa and palate, bilateral facial and jaw enlargement due to hyperostotic osteodystrophy, abnormally flexible mandibles, and, in some cases, pathological mandibular fractures; these dogs can also have generalized osteodystrophy.9 Clinical probing depths were found to be unaffected, despite radiographic signs of periodontal bone loss, in a study13 of the cadavers of dogs that had an antemortem diagnosis of secondary hyperparathyroidism and renal osteodystrophy. Severe demineralization of maxillary and mandibular trabecular bone resulting from imbalances in osteoclastic and osteoblastic activity results in fibrous osteodystrophy9,14 and creates the radiographic appearance of teeth floating in space.9

The hallmark of primary hyperparathyroidism is high serum concentration of ionized calcium in the presence of a normal or high serum parathyroid hormone concentration; in dogs with this condition, circulating phosphorus concentrations are low to normal, there is no azotemia, and urine may or may not be concentrated.12 Primary hyperparathyroidism is commonly associated with a functional parathyroid adenoma but can result from adenomatous hyperplasia or parathyroid gland carcinoma.12 In dogs with secondary hyperparathyroidism attributable to chronic renal disease, azotemia, isosthenuria, hyperphosphatemia, and high circulating parathyroid hormone concentrations are common findings, and serum alkaline phosphatase activity may be increased.12 Abdominal ultrasonography may reveal small kidneys. In dogs with nutritional secondary hyperparathyroidism, serum biochemical findings are often normal, and there is a history of being fed a diet with excess phosphate, insufficient calcium, or both.12 Clinical signs include lameness, signs of skeletal pain, and reluctance to walk or stand.12 Tertiary hyperparathyroidism can develop when chronic secondary hyperparathyroidism results in autonomous secretion of parathyroid hormone without a response to negative feedback controls, despite elimination or management of the inciting cause.9 Review of treatments for secondary hyperparathyroidism was beyond the scope of this report. However, in a clinical report15 of a human patient with oral manifestations of secondary hyperparathyroidism, there were no appreciable clinical or radiographic changes in bony lesions in response to medical management of chronic renal disease and parathyroidectomy.

The dog of the present report had evidence of primary hyperparathyroidism on serum biochemical analysis and cervical ultrasonographic findings when it was seen for the first annual oral examination and dental cleaning. By the second annual visit, the patient had developed clinical signs consistent with primary hyperparathyroidism, including weight loss, urinary incontinence, and atrophy of the temporal muscles. After being shown the new radiographic changes at the third annual oral examination, the client accepted referral of the dog for parathyroidectomy. The serial dental radiographs were a key aid in convincing the client that treatment of primary hyperparathyroidism was in the best interest of the patient. Nine months after the surgery, there was radiographic evidence showing restoration of the lamina dura and alveolar margins in most affected sites. At the fifth annual oral examination, 21 months after surgery, the trabecular bone pattern, widening of the periodontal ligament, and ill-defined alveolar margin had continued to improve and resolve, except for the irregular margin on the mesial aspect of the mesial root of the left mandibular first molar tooth. Widening of the periodontal ligament space surrounding teeth correlates with serum parathyroid hormone concentrations in people with primary hyperparathyroidism.8 It can also be associated with periodontal attachment loss, making differentiation between diagnoses imperative for appropriate treatment planning. The recommended treatment of teeth with stage 4 periodontal disease (> 50% radiographically assessed bone loss)1 and teeth with combined severe periodontal-endodontal lesions is most often extraction.16 In the dog of the present report, most of the radiographic lesions resolved with surgical excision of the parathyroid nodule, and dental extractions were not indicated. To the authors' knowledge, reversibility of the bone loss in primary hyperparathyroidism, as seen on serial dental radiographs, has not been previously reported in dogs or people.

Acknowledgments

The authors declare that there were no conflicts of interest. The authors thank Dr. Amy Stone for editorial contributions.

Footnotes

a.

Proin Chewable Tablets, Pegasus Laboratories Inc, Pensacola, Fla. 1109

b.

Calcitriol, Strides, Riviera Beach, Fla.

c.

Royal Canin Renal Support, St Charles, Mo.

d.

Hill's Prescription Diet k/d, Topeka, Kan.

References

  • 1. American Veterinary Dental College. AVDC nomenclature. Available at: www.avdc.org/avdc-nomenclature/. Accessed Nov 13, 2019.

  • 2. Holmstrom S, Frost P, Eisner E. Dental records. In: Veterinary dental techniques for the small animal practitioner. 3rd ed. Philadelphia: Saunders, 2004;20.

    • Search Google Scholar
    • Export Citation
  • 3. Dupont GA, DeBowes LJ. Intraoral radiographic anatomy of the dog. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;32.

    • Search Google Scholar
    • Export Citation
  • 4. International Renal Interest Society. IRIS staging of CKD (modified 2017). Available at: www.iris-kidney.com/pdf/IRIS_2017_Staging_of_CKD_09May18.pdf. Accessed Jul 24, 2019.

    • Search Google Scholar
    • Export Citation
  • 5. Dupont GA, DeBowes LJ. Endodontic disease. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;151154.

  • 6. Marretta SM, Schloss AJ, Klippert LS. Classification and prognostic factors of endodontic-periodontic lesions in a dog. J Vet Dent 1992;9:2730.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7. Rai S, Bhadada SK, Rattan V, et al. Oro-mandibular manifestations of primary hyperparathyroidism. Indian J Dent Res 2012;23:384387.

  • 8. Padbury AD Jr, Tözüm TF, Taba M Jr, et al. The impact of primary hyperparathyroidism on the oral cavity. J Clin Endocrinol Metab 2006;91:34393445.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Davis EM. Oral manifestations of chronic kidney disease and renal secondary hyperparathyroidism: a comparative review. J Vet Dent 2015;32:8798.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10. World Small Animal Veterinary Association. Body condition score—dog. Available at: wsava.org/Global-Guidelines/Global-Nutrition-Guidelines. Accessed Jan 6, 2020.

    • Search Google Scholar
    • Export Citation
  • 11. Dupont GA, DeBowes LJ. Miscellaneous conditions. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;221222.

    • Search Google Scholar
    • Export Citation
  • 12. Feldman EC. Disorders of the parathyroid glands. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 6th ed. St Louis: Elsevier, 2005;15081519.

    • Search Google Scholar
    • Export Citation
  • 13. DeSanctis M. Renal osteodystrophy as a cause of periodontal manifestations: clinical and histologic studies in dogs. Mondo Odontostomatol 1985;27:1725.

    • Search Google Scholar
    • Export Citation
  • 14. Sarkiala EM, Dambach D, Harvey CE. Jaw lesions resulting from renal hyperparathyroidism in a young dog—a case report. J Vet Dent 1994;11:121124.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15. Kakade SP, Gogri AA, Umarji HR, et al. Oral manifestations of secondary hyperparathyroidism: a case report. Contemp Clin Dent 2015;6:552558.

  • 16. Lommer JL. Principles of exodontics. In: Oral & maxillofacial surgery in dogs and cats. Edinburgh: Elsevier,

Appendix

Body weight, body condition score, and selected clinicopathologic findings at the time of 3 consecutive annual visits for a spayed female mixed-breed dog that was presented to a veterinary hospital for oral examination, dental radiography, and routine periodontal treatment.

 Annual visit 
Variable123Reference range
Body weight (kg)18.115.814
Body condition score7/95/93/9*
Serum analytes
  Total calcium (mg/dL)12.413.712.78.9–11.4
  Ionized calcium (mmol/L)1.741.931.24–1.43
  Phosphorus (mg/dL)2.12.24.42.5–6.0
  Parathyroid hormone (pmol/L)2.332.20.5–5.8
  Creatinine (mg/dL)1.01.21.50.6–1.6
Urine specific gravity1.0161.0151.0111.015–1.050

The dog was 9 years old and weighed 14 kg (30.8 lb) at the third annual visit.

The body condition scoring system used ranged from 1 to 9, with 5 considered ideal.10

— = Not applicable.

Contributor Notes

Address correspondence to Dr. Hoffman (shoffmandvm@comcast.net).
  • Figure 1—

    Selected bisecting angle (A and B) and parallel (C and D) radiographic views of the teeth of a 9-year-old mixed-breed dog that was presented for routine oral examination and dental cleaning. A—Right maxillary second and first molar teeth, fourth premolar tooth, and third premolar tooth distal root. B—Left maxillary second premolar tooth distal root, third and fourth premolar teeth, and first molar tooth. C—Right mandibular second and first molar teeth. D—Left mandibular fourth premolar tooth distal root, first molar tooth, and roots of the second molar tooth.

  • Figure 2—

    Same radiographic images as in Figure 1. Absence of the lamina dura and widening of periodontal ligament space around tooth roots (A through D; thin arrows), loss of the trabecular bone pattern in interradicular and interalveolar septa (A, B, and D; thick arrows), and poorly defined alveolar margins (B and D; forked thick arrow) are evident.

  • Figure 3—

    Selected bisecting angle (A and B) and parallel (C and D) radiographic views of the teeth of the dog in Figure 1 obtained 9 months after right cranial parathyroidectomy. A—Right maxillary second and first molar teeth and fourth premolar tooth. The trabecular bone pattern and lamina dura are present in the periradicular and interradicular areas of the fourth premolar tooth. B—Left maxillary second and third premolar teeth and mesial roots of the fourth premolar tooth. The trabecular bone pattern is evident in the interradicular and interalveolar septa of the premolar teeth. Lamina dura is present, and the alveolar margin is defined between the third and fourth premolar teeth at the level of the cementoenamel junctions. C—Right mandibular second molar tooth roots, first molar tooth, and fourth premolar tooth (distal aspect). Lamina dura is present in most areas. There is widening of the periodontal ligament space (thin arrow) at the coronal aspect of the distal root of the first molar tooth and vertical bone loss between the fourth premolar and first molar teeth (dotted arrow). D—Left mandibular fourth premolar tooth (distal root), first molar tooth, and mesial root of the second molar tooth. Lamina dura is present at most of the root surfaces except the mesial aspect of the mesial root of the first molar tooth; the trabecular bone pattern at this site is irregular, with an area of radiopacity at the apex of the mesial root (arrowhead). There is an irregular margin on the mesial aspect of the mesial midroot of the first molar tooth (caret). The alveolar margin is ill-defined between the first and second molar teeth (forked arrow).

  • 1. American Veterinary Dental College. AVDC nomenclature. Available at: www.avdc.org/avdc-nomenclature/. Accessed Nov 13, 2019.

  • 2. Holmstrom S, Frost P, Eisner E. Dental records. In: Veterinary dental techniques for the small animal practitioner. 3rd ed. Philadelphia: Saunders, 2004;20.

    • Search Google Scholar
    • Export Citation
  • 3. Dupont GA, DeBowes LJ. Intraoral radiographic anatomy of the dog. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;32.

    • Search Google Scholar
    • Export Citation
  • 4. International Renal Interest Society. IRIS staging of CKD (modified 2017). Available at: www.iris-kidney.com/pdf/IRIS_2017_Staging_of_CKD_09May18.pdf. Accessed Jul 24, 2019.

    • Search Google Scholar
    • Export Citation
  • 5. Dupont GA, DeBowes LJ. Endodontic disease. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;151154.

  • 6. Marretta SM, Schloss AJ, Klippert LS. Classification and prognostic factors of endodontic-periodontic lesions in a dog. J Vet Dent 1992;9:2730.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7. Rai S, Bhadada SK, Rattan V, et al. Oro-mandibular manifestations of primary hyperparathyroidism. Indian J Dent Res 2012;23:384387.

  • 8. Padbury AD Jr, Tözüm TF, Taba M Jr, et al. The impact of primary hyperparathyroidism on the oral cavity. J Clin Endocrinol Metab 2006;91:34393445.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Davis EM. Oral manifestations of chronic kidney disease and renal secondary hyperparathyroidism: a comparative review. J Vet Dent 2015;32:8798.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10. World Small Animal Veterinary Association. Body condition score—dog. Available at: wsava.org/Global-Guidelines/Global-Nutrition-Guidelines. Accessed Jan 6, 2020.

    • Search Google Scholar
    • Export Citation
  • 11. Dupont GA, DeBowes LJ. Miscellaneous conditions. In: Atlas of dental radiography in dogs and cats. St Louis: Saunders, 2009;221222.

    • Search Google Scholar
    • Export Citation
  • 12. Feldman EC. Disorders of the parathyroid glands. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 6th ed. St Louis: Elsevier, 2005;15081519.

    • Search Google Scholar
    • Export Citation
  • 13. DeSanctis M. Renal osteodystrophy as a cause of periodontal manifestations: clinical and histologic studies in dogs. Mondo Odontostomatol 1985;27:1725.

    • Search Google Scholar
    • Export Citation
  • 14. Sarkiala EM, Dambach D, Harvey CE. Jaw lesions resulting from renal hyperparathyroidism in a young dog—a case report. J Vet Dent 1994;11:121124.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15. Kakade SP, Gogri AA, Umarji HR, et al. Oral manifestations of secondary hyperparathyroidism: a case report. Contemp Clin Dent 2015;6:552558.

  • 16. Lommer JL. Principles of exodontics. In: Oral & maxillofacial surgery in dogs and cats. Edinburgh: Elsevier,

Advertisement