Radical debridement guided by advanced imaging and frequent monitoring is an effective approach for the treatment of odontogenic abscesses and jaw osteomyelitis in rabbits: a review of 200 cases (2018–2023)

Vladimir Jekl Jekl & Hauptman Veterinary Clinic – Focused on Exotic Companion Mammal Care, Brno, Czech Republic
Department of Pharmacology and Pharmacy, Faculty of Veterinary Medicine, University of Veterinary Sciences Brno, Brno, Czech Republic

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Edita Jeklova Department of Infectious Diseases and Preventive Medicine, Veterinary Research Institute, Brno, Czech Republic

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Karel Hauptman Jekl & Hauptman Veterinary Clinic – Focused on Exotic Companion Mammal Care, Brno, Czech Republic

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Abstract

OBJECTIVE

To report the prevalence and document the treatment and outcome of odontogenic abscesses and associated jaw osteomyelitis in pet rabbits.

ANIMALS

200 client-owned rabbits.

METHODS

Pet rabbits surgically treated using extraoral teeth extraction with marsupialization for abscesses of dental origin and jaw osteomyelitis were included in the study (February 2018 to February 2023). A case must have had pre- and postoperative computed tomographic study and a follow-up period of at least 4 months.

RESULTS

In total, 113 male and 87 female rabbits were treated surgically. The mean age at the time of the diagnosis at the authors' clinic was 3 years and 11 months. Male rabbits suffered from odontogenic abscesses significantly more often than females. The mean surgical time varied from 25 to 95 minutes, based on the severity of the pathology and location. The wound healed completely in an average of 39.7 days (range, 14 to 145 days; 95% CI, 36.9 to 42.5 days). Major complications detected in 18.5% (37/200) cases were associated with prolonged healing time mostly due to the formation of a bone sequestrum and gingival suture failure. The disease-free time following abscess resolution was on average 29 months (range, 4 to 60 months). The recurrence of the odontogenic infection was 8% (16/200 cases).

CLINICAL RELEVANCE

The radical surgical technique with the extraction of all the infected teeth with the removal of all affected tissue and osteomyelitic bone and regular follow-up wound management is an effective method for the treatment of odontogenic abscesses with jaw osteomyelitis.

Abstract

OBJECTIVE

To report the prevalence and document the treatment and outcome of odontogenic abscesses and associated jaw osteomyelitis in pet rabbits.

ANIMALS

200 client-owned rabbits.

METHODS

Pet rabbits surgically treated using extraoral teeth extraction with marsupialization for abscesses of dental origin and jaw osteomyelitis were included in the study (February 2018 to February 2023). A case must have had pre- and postoperative computed tomographic study and a follow-up period of at least 4 months.

RESULTS

In total, 113 male and 87 female rabbits were treated surgically. The mean age at the time of the diagnosis at the authors' clinic was 3 years and 11 months. Male rabbits suffered from odontogenic abscesses significantly more often than females. The mean surgical time varied from 25 to 95 minutes, based on the severity of the pathology and location. The wound healed completely in an average of 39.7 days (range, 14 to 145 days; 95% CI, 36.9 to 42.5 days). Major complications detected in 18.5% (37/200) cases were associated with prolonged healing time mostly due to the formation of a bone sequestrum and gingival suture failure. The disease-free time following abscess resolution was on average 29 months (range, 4 to 60 months). The recurrence of the odontogenic infection was 8% (16/200 cases).

CLINICAL RELEVANCE

The radical surgical technique with the extraction of all the infected teeth with the removal of all affected tissue and osteomyelitic bone and regular follow-up wound management is an effective method for the treatment of odontogenic abscesses with jaw osteomyelitis.

Exotic companion herbivorous mammals are commonly kept as pets in Europe, the US, Asia, and Australia. With the increasing popularity of such pets, the complexity of diagnostic and surgical procedures performed in small mammals is increasing.

Oral and dental pathology is one of the most common disorders encountered in exotic companion mammals (pet rabbits, guinea pigs, chinchillas, and degus), with the highest prevalence in degus (60%).13 In rabbits, published figures for the prevalence of dental disease include 6.7% (7/105 rabbits),4 10.9% (272 rabbits out of 2,506 animals),5 and 38.1% (80/210 animals).6 In a study7 of rabbits considered healthy by the owners, the prevalence of dental disease confirmed by radiography was 40.1% (67/167 rabbits). Therefore, the true prevalence of dental disease in rabbits is higher than what is evident clinically.

A wide range of local and systemic conditions that affect the mouth and oral cavity have been described: hereditary, infectious, metabolic (calcium metabolic disorders), lack of chewing, a diet that is insufficiently abrasive, traumatic (including foreign bodies), iatrogenic, and neoplastic.2,6,8 Dental disease may be clinically manifested by obvious incisor clinical crown elongation, hypersalivation, moist dermatitis, anorexia, chewing disturbances, change of feed preferences, and weight loss.2,6,8,9 Factors that affect tooth positioning, such as abnormalities of jaw width, length, and height may also result in malocclusion, as may variations in tooth arrangement along the jaw, the degree of eruption, tooth rotation, and tipping (tooth tilting).2,6,8 To describe the complexity of the various pathologies of dental disease and their associated clinical signs, the term “syndrome of dental disease” or “progressive syndrome of acquired dental disease” was proposed.8

Acquired dental disease may be accompanied by the development of odontogenic abscesses; however, they can also occur in rabbits with good dentition.8 Information about the prevalence of odontogenic abscesses is lacking with only 1 article6 clearly stating the prevalence of 8.8% (22/210 rabbits). Due to late diagnosis or improper treatment, periapical abscesses (odontogenic, dentoalveolar abscesses) in rabbits can lead to the development of severe osteomyelitis, with subsequent anorexia and eventual animal death. The etiology of odontogenic abscesses is complex; however, the most common cause is periapical bacterial infection of a diseased or damaged tooth.8 Due to the widening of interdental spaces associated with pathological orthodontic tooth movement seen in rabbits with the syndrome of acquired dental disease, parts of the feed become impacted in the periodontal space, causing periodontitis, with subsequent tooth and alveolar bone damage. As the disease progresses, osteomyelitis occurs and purulent exudate spreads into the adjacent soft tissues, which may present clinically as facial masses, respiratory disorders (rhinitis or paranasal cavity infection/empyema), or exophthalmia (retrobulbar or parabulbar pus accumulation). Other causes of odontogenic abscess formation include penetration of elongated premolar and molar clinical crowns through the buccal gingiva causing cheek abscesses, and iatrogenic pulpal damage due to improper teeth trimming.8,9 According to Harcourt-Brown and Chitty,9 odontogenic abscesses can be divided into abscesses involving a single infected tooth, abscesses containing very elongated tooth apices, abscesses with a bony capsule, and abscesses with subcutaneous fibrous tracts to distant sites. Odontogenic abscesses can also be classified based on the site of the infection.8

The thick consistency of rabbit pus makes aspiration and drainage of these abscesses very difficult and antibiotic therapy alone problematic.9 Therefore, during the surgical procedure, it is appropriate to take samples for microbiological culture and susceptibility testing of the isolated bacteria to antibiotics. The optimal specimens are the capsule of the abscess, the affected tooth/teeth, and the affected bone. Bacterial pathogens commonly involved in periapical lesions are Fusobacterium nucleatum, Prevotella spp, Peptostreptococcus micros, Streptococcus milleri group, Actinomyces israelii, and Arcanobacterium haemolyticum.10 Other studies showed the most frequently isolated anaerobic bacteria are Bacteroides spp, Prevotella oris, Actinomyces spp and Fusobacterium nucleatum,11 or Pseudomonas aeruginosa, Pasteurella spp, Fusobacterium spp, Peptostreptococcus spp, and Bacteroides spp.12

Diagnosis of odontogenic infection/abscess/empyema is based on a combination of intraoral cavity inspection and imaging methods. Extraoral and intraoral radiography, oral cavity endoscopy, and CT are the most commonly used imaging methods. Computed tomography scans should be performed in all cases of facial odontogenic abscesses/osteomyelitis to enable exact lesion localization, proper surgical planning, and determination of prognosis. Computed tomography images also have the advantage of evaluation of each particular tooth and the surrounding bony tissue.

Treatment of odontogenic abscesses is challenging as the prognosis and ease of treatment vary with each case and depend on the site of the infection, number of affected teeth, extent and severity of bone loss and osteomyelitis, stage of dental disease, and presence of concurrent disorders. It has been published9 that successful treatment is based on a combination of surgical intervention and antibiotic administration to clear the residual infection.

The treatment, outcome, and prognosis are not sufficiently described in the literature and are based on isolated cases1316; case studies with 7,17 10,18 13,19,20 or 20 animals21; or descriptive discussions of prognosis and possible treatments.1,9,2226

The objective of this retrospective study was to describe the treatment outcomes of jaw osteomyelitis of odontogenic origin in 200 pet rabbits.

Methods

Case selection and inclusion criteria

In this study, only pet rabbits surgically treated at the authors' clinic for abscesses of dental origin with jaw infection were included in the study. The diagnosis had to have been confirmed via CT, and all patients needed to be monitored for a period at least of 4 months, with all relevant information recorded in the patient's case file. The study period spanned from February 2018 to February 2023.

All the rabbits received a general physical examination before the diagnostic workup, which included intraoral cavity examination, urine evaluation, plasma chemistry and blood hematology assessment, and CT (cone beam CT scanner; NewTom GiANO HR; slice thickness, 68 μm; voltage, 90 kVp; automatically calculated exposure time) of the head under general anesthesia (IM premedication with 1 mg/kg alfaxalon, 0.1 mg/kg midazolam, 0.1 mg/kg butorphanol, and 1 to 3% isoflurane). In 40 cases, a contrast CT examination was performed (300 to 600 mg/kg, IV, iopamidol or iohexol). The oral cavity was inspected using a rigid endoscope as described by Jekl and Knotek.27 Computed tomography was also performed postoperatively to ensure the complete removal of all dental hard tissue and osteomyelitic bone. Computed tomography images were evaluated in axial, coronal, and sagittal planes, with multiplanar reconstruction and 3-D reconstruction images included.

Odontogenic abscesses were further divided based on the site of infection, ie, rostral mandible (infection of the incisor and P3 and P4), mandibular body (infection of more than 3 cheek teeth), caudal mandible (infection of M3 and M2), rostral maxilla (infection of incisor and maxillary P2 and P3), alveolar bulla infection/empyema (infection of more than 4 cheek teeth), and caudal maxilla (infection of M3 and M2).

Before the surgical procedure, the patient was stabilized, and if any intraoral dental procedure was indicated, it was performed 2 to 10 days before the surgery.

Surgical procedure

The surgical procedures were performed by 1 of the authors (VJ or KH), who are both experienced surgeons with at least 20 years of practice with exotic companion mammals. The anesthetic protocol comprised multimodal analgesia and anesthesia, including continuous rate infusion (0.3 mg/kg/h ketamine). In the case of rostral mandibular surgeries, the mandibular nerve block with lidocaine (1 mg/kg) was used.28 Surgery was performed under general anesthesia with the rabbits intubated. General anesthesia was induced using a combination of 0.3 mg/kg methadone or 0.03 mg/kg buprenorphine, 50 mg/kg metamizole, 0.1 mg/kg midazolam, 0.02 to 0.03 mg/kg medetomidine, and 5 to 10 mg/kg ketamine and was maintained using isoflurane with or without ketamine continuous rate infusion (0.3 mg/kg/h). The patient was placed on a heating pad and monitored throughout the surgery and anesthetic recovery period. Anesthetic monitoring included respiratory rhythm and depth monitoring, thoracic auscultation, ECG, and SpO2 measurement. Isotonic fluid therapy (10 mL/kg) was administered perioperatively via continual infusion.

The surgery itself was performed with the patient in lateral or dorsal recumbency and under aseptic conditions with the skin surgically prepared, using an extraoral approach or a combination of extraoral and intraoral teeth extractions. To facilitate the approach to the affected teeth and bone, a lone-star retractor was used in all cases.

For treatment of the mandibular teeth, a skin incision parallel to the long axis of the mandible overlying the lesion was performed. After soft tissue dissection, the abscess capsule or affected bone was identified. The diseased tissue was then dissected from the surrounding tissue, the capsule was excised, pus was removed using sterile cotton tips, and infected bone and affected tissues were debrided using a bone curette. If the affected teeth were not immediately visualized, an osteotomy of the mandibular bone was performed using dental burrs (preferably using a carbide dental bur round ball). The affected tooth/teeth were luxated (double-ended molar luxator for extraction rabbit molars) and extracted (using artery forceps, needle holder, or dental root fragment forceps) extraorally or using a combined extraoral and intraoral approach. In the case of challenging tooth luxation and extraction, the affected premolar or molar reserve crown was transected into 2 parts using a low-speed or preferably high-speed handpiece with a dental drill, which facilitated luxation, and the apical and coronal part of the tooth was extracted extraorally. Soft tissues were then marsupialized to the skin using monofilament or polyfilament absorbable suture material (4/0) and a single interrupt suture pattern. The inner part of the abscess was again debrided, and a 0.2% solution of potassium permanganate was used to dry the wound surface to reduce the bacteria number and to support wound healing. If the incisor was also affected, it was extracted.

In the case of maxillary odontogenic abscesses of P2 and P3, the surgery was comprised of a skin incision overlying the mass, identification of the diseased tissue, and extraoral extraction of the affected teeth. If necessary, the rostral part of the zygomatic arch was removed. If maxillary P4-M1 or the zygomatic arch was affected, the skin was incised dorsal to the zygomatic arch. Soft tissues and muscles were sharply dissected from all aspects of the rostral third to half of the zygomatic arch with subsequent ostectomy of the rostral third of the zygomatic arch and osteotomy of the lateral wall of the maxillary alveolar bulla (removal using a low- or high-speed handpiece with round end or round end fissure dental burr). The affected tooth/teeth were luxated and extracted extraorally or using a combined extraoral and intraoral approach. In cases where only the last 2 molars were affected, only part of the zygomatic arch overlying the lesion was removed. Alternatively, a technique without any zygomatic arch removal was performed. The affected teeth were luxated, and the soft tissues were then marsupialized to the skin. The maxillary surgical procedure aimed to save the eye whenever possible. The inner part of the abscess was again debrided, and a solution of potassium permanganate was used to dry the wound surface to reduce the bacteria number and to support wound healing. If the incisor was also affected, it was extracted. In 16% of cases (32 animals), gentamicin-soaked collagen cones were placed extraorally to the sutured gingiva to support the gingival suture.

Whether the mandibular or maxillary tooth/teeth were affected, intraoral gingival suture (simple interrupted or continuous suture pattern, absorbable or nonabsorbable suture material 4/0) was performed in all the cases. In 12 cases of full maxillary premolar and molar teeth extraction, the gingival suture was performed extraorally.

In all cases, a sample for bacteriology was taken and antimicrobial susceptibility for anaerobic and aerobic bacteria was established.

Postoperative radiography or CT imaging was performed immediately after the surgery and 2 to 6 months after the surgery. If any signs of delayed wound healing were noted, repeated CT imaging was performed.

Postoperative care and follow-up data

Postoperative care consisted of supportive care, fluid therapy and, if necessary, assisted feeding. Penicillin G (60,000 IU/kg, IM, q 12 h) and oral doxycycline (5 mg/kg, q 12 h) were administered as first-choice antibiotics. Alternatively, oral metronidazole (30 mg/kg, q 12 h) and oral enrofloxacin (10 mg/kg, q 12 h) or IM marbofloxacin (5 mg/kg, q 24 h) were used. Fluoroquinolones were used only in animals as a continuation of previous treatments from referral clinics for at least 7 days of antibiotic treatment to avoid possible antibiotic resistance issues. Further antibiotic treatment was based on the results of antibiotic bacterial susceptibility testing. Antibiotic treatment was advocated for 7 to 21 days. For analgesia, a combination of an opioid (methadone, 0.3 mg/kg, IM, q 4 h; or buprenorphine, 0.03 mg/kg, IM, q, 6 to 8 h) with NSAIDs (meloxicam, 1 mg/kg, SC, or orally q 24 h or metamizole 20-50 mg/kg, IM q8h) and gabapentin (25 mg/kg orally, q 12 h) was advocated.

Analgesic drugs were discontinued after 6 weeks; however, some animals received analgesics for a longer period due to the presence of more advanced acquired dental disease.

The clients were requested to not perform any wound care themselves. Instead, the surgical site was reevaluated under general anesthesia at the authors' clinic on days 3 to 5, 7 to 10, 12 to 16, 28 to 32, and 35 to 50 and then in 2- to 4-month periods as a postrecovery recheck. The wound was thoroughly inspected and debrided if needed. The skin sutures were removed between day 5 and day 14 after surgery, and the intraoral sutures were removed between day 10 and day 16 after surgery. Once the cutaneous sutures were removed, the surgical site healed quickly.

The final time of healing was determined to be the time from the day of surgery until complete wound healing (skin closure and epithelization without any other radiographic or CT pathologies; Figure 1).

Figure 1
Figure 1

Graphical distribution of the healing process in mandibular and maxillary abscesses in 200 pet rabbits.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

If wound healing was delayed, CT was repeated, and the odontogenic abscess was reoperated.

Statistical analysis

The data (age, number of male and female rabbits, presence of a lesion in maxilla or mandible, and healing time) were tested using the Shapiro-Wilk normality test and were not normally distributed. Quantitative data were expressed as means minimal and maximal value and 95% CI. A Pearson χ2 test was performed on proportional data. Quantitative data were compared using ANOVA nonparametric test. Multivariable logistic regression was used to compare the age when presented with odontogenic abscess, presence of the lesion on maxilla or mandible, lesion present in a male or female animal, and healing time. All calculations were performed with GraphPad Prism 10 and Microsoft Excel. The a priori significance levels were established as P < .05.

Results

Two hundred twenty-two rabbits (8.5%) met the inclusion criteria of the presence of odontogenic abscesses from a total of 2,624 rabbits presented to the clinic. From these animals, 2 rabbits died during or immediately after the surgery due to anesthetic complications and 19 were euthanized during the first visit, as the client was not able to provide home care for the 3 weeks following surgery, or the client was not able to present the patient for follow-up examinations. Therefore, 200 pet rabbits were included in further statistical data analyses. From these 200 clinical cases of odontogenic abscesses, 81% of cases (162 animals) were already treated with antibiotics, analgesia, or surgery at another veterinary practice for 5 days to 6 months. In total, 113 male (82 intact and 31 neutered) and 87 female (40 intact and 47 spayed) rabbits were treated surgically. The average age at the time of diagnosis at the authors' clinic was 3 years and 11 months with the youngest animal being 4.2 months and the oldest 11 years of age. The average body weight was 2 ± 0.8 kg (0.4 to 6.25 kg body weight, minimum to maximum). When comparing sex, males suffered from odontogenic abscesses significantly more often than females (P < .01). Multivariable logistic analysis did not show any significant changes in odd ratios and estimates when compared the age, sex, presence of the abscess on maxilla/mandible, or healing time of rabbits with odontogenic abscess.

Computed tomography and intraoral cavity inspection under general anesthesia provided clinically valuable information regarding the odontogenic abscesses. Based on CT, 207 odontogenic abscesses were diagnosed in 200 rabbits. Teeth in the left mandibular quadrant were affected in 60 cases, in the right mandibular quadrant in 66 cases, in the left maxillary quadrant in 37 cases, and in 44 cases the maxillary right quadrant was affected (Figures 26). In 7 cases, osteomyelitis, was present in more than 1 dental quadrant at the time of diagnosis. Rostral mandibular abscess, mandibular body infection, caudal mandibular abscess, alveolar bulla infection/empyema, and caudal maxillary abscess infection were identified in 42, 68, 22, 29, 46, and 15 cases, respectively. When comparing the anatomical location of infection, no statistical significance was found. More than 1 tooth was affected in 99% (198 cases).

Figure 2
Figure 2

Healing of the surgical wound associated with total maxillary premolar and molars extraction a 4-year-old rabbit (A through C). A—Surgical wound immediately after the surgery with the patient intubated. B—Surgical wound with small crust formation 20 days after the surgery. C—The wound is almost completely healed. The wound was classified as healed in the next 2 days. Image courtesy Vladimíir Jekl.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

Figure 3
Figure 3

Odontogenic abscess in a 5-year-old spayed female rabbit (A through G). Ventrolateral mass was associated with the infection of the mandibular right incisor and premolar P3 and osteomyelitis of the mandible (A and E through G). B—3-D cone beam CT (CBCT) reconstruction of the head with pronounced osteomyelitis of the rostral mandible. C and D—CBCT transverse (C) and coronal (D) section of the mandible showing medial and lateral mandibular lysis at the area of mandibular incisor and P3. E—Debridement of the abscess cavity using a bony curette. F—Identification of the affected premolar. G—Mandibular incisor after the extraction. Image courtesy Vladimíir Jekl.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

Figure 4
Figure 4

Odontogenic abscess in a 2.5-year-old intact female rabbit (A through J). Extraction of all the mandibular premolars and molars was performed due to extensive mandibular lysis. Surgical approach to the mandibular body with skin incision above the facial mass (B), abscess capsule incision (C), and pus removal and debridement (D and E). Note extensive mandibular bone damage from the medial and lateral sides. Computed tomography images of the rabbit with panoramic view (F) and CBCT 3-D (G) reconstruction showing infection that affects mandibular bone and P4-M3. CBCT images of a rabbit 10 months after the surgery (H through J) show a successful healing process with new dental substance (dentinoid, arrowhead) formation and without infection. Image courtesy Vladimíir Jekl.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

Figure 5
Figure 5

Maxillary abscess in 2-year-old intact male rabbit (A through F). CBCT images of a rabbit with maxillary alveolar bulla empyema and infection before (A, D, and C) and immediately after the surgical procedure (B, E, and F). The zygomatic arch is missing, and in the maxillary bulla, the air is present within the left maxillary alveolar bulla (B, E, and F). Note the presence of the tracheal tube (F). Image courtesy Vladimíir Jekl.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

Figure 6
Figure 6

Endoscopic images of a rabbit, presented in Figure 3, 6 weeks after the extraction of all the left maxillary premolars and molars (A through D). A and B—Detailed view of the extraction site, where only healed gingiva is present without any signs of infection. C and D—Detailed view of the right (C) and left (D) mandibular arcade. Note the presence of a sharp point in the clinical crown of the mandibular right M3 and irregular occlusion of the left mandibular last molar (D). Image courtesy Vladimíir Jekl.

Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0332

Perioperative CT or radiography was used to confirm that the surgical site was completely debrided of pathological bony and dental tissue. In cases where remnants of bony or dental tissue remained, the surgery continued until all remnants were removed. This was encountered in 14% (28/200) of cases.

Minor intraoperative anesthetic complications were encountered in 16 cases (apnoea) and major intraoperative complications in 4 cases (asystole), which resulted in the death of 2 animals (mortality of 0.1%).

The surgical time varied from 25 to 95 minutes (mean 46 minutes) based on the severity of the pathology and location. In total, 207 surgeries were performed as 7 rabbits were operated on 2 jaw quadrants. The rostral mandibular approach, caudal mandibular approach, and total unilateral premolar and molar extractions were performed in 36, 22, and 68 cases, respectively. The ipsilateral mandibular incisor was extracted in 32 cases. Rostral maxillary approach, caudal maxillary approach, and total unilateral premolar and molar extractions were performed in 20, 15, and 46 cases, respectively. The ipsilateral maxillary incisor needed to be extracted due to infection in 3 cases. Due to severe retrobulbar space infection, the eye was enucleated in 3 cases. In another 57 cases, the eye was saved. Paranasal cavity infection or rhinitis associated with maxillary premolar infection was present in 18 cases. In total, 757 teeth were extracted (420 mandibular and 337 maxillary teeth).

The surgical site healed completely (both mandibular and maxillary surgery) in an average of 39.7 ± 1.41 days (range, 14 to 145 days; 95% CI, 36.9 to 42.5 days). The healing period of mandibular and maxillary surgical wounds was not statistically different.

Postoperatively, the majority of cases (78% [156/200]) started to eat on their own immediately after anesthetic recovery. The rest of the animals were force fed with the critical care diet (1:2 combination of the Emerid Intensive Care Herbivore and Supreme Science Selective Recovery Plus) until they started to eat spontaneously (within the next 1 to 10 days).

Aerobic and anaerobic cultures demonstrated the presence of mixed infection. The most commonly cultivated pathogens were Streptococcus intermedius, Gemella morbillorum, Prevotella heparinolytica, Fusobacterium spp, Trueperella pyogenes, and Actinomyces spp. Negative results (sterile infection) were recorded only in 5% of cases.

During the first 2 surgical wound examinations under general anesthesia, the presence of partial wound closure with crust and debris (81 cases), impaction of the wound with hairs (34 cases), gingival suture failure (32 cases) mostly associated with iatrogenic damage by the client during syringe feeding, accumulation of necrotic material and pus in the wound (15 cases), and wet dermatitis of the neck area (14 animals) was detected. All these complications were immediately addressed (ie, wound debridement, repeated gingival suture) during these follow-up anesthetic events. Other complications seen detected in 18.5% (37/200) cases were associated with prolonged healing time and included the formation of a bone sequestrum (25 cases), repeated gingival failure (3 cases), repeated paranasal cavity infection (4 cases), infection of new tooth substance (3 cases), and mandibular fracture (2 cases). From these rabbits, gingival suture was performed again in 3 cases, and 32 animals were operated again. Disease-free time following abscess resolution was 29 months (mean) with a range from 4 months to 60 months, with the majority of patients still living.

Recurrence of the odontogenic infection in the previously operated mandible or maxilla was 8% (16/200) of cases. From these animals, 11 rabbits were euthanized and another 5 were surgically treated again. In total, 37 animals (18.5%) were repeatedly surgically treated for persistent or recurrent infection. Recurrence of the odontogenic abscess occurred at an average of 5.5 months (mean) after the wound was healed (range, 3 to 12 months; 95% CI, 4.3 to 6.8 months).

Only 5.5% (11/200 rabbits) of cases were euthanized due to repeated infections or client home care refusal. A total of 12.5% (25/200 animals) of patients were euthanized for reasons other than odontogenic abscesses, while 82% of patients (164/200) were still alive at the end of the study period. Survival analysis data were applied to all the patients included in the study.

Discussion

To the authors' knowledge, this is the largest retrospective study on the treatment of odontogenic abscesses and jaw osteomyelitis in pet rabbits.

The prevalence of odontogenic abscesses was found to be 8.5% (222/2,624 pet rabbits presented to the clinic), which is similar to a previous study6 from the year 2008. Since the authors' clinic is a referral center for exotic companion mammals, the prevalence of odontogenic abscesses is likely higher than first opinion practices. Several articles, including Siriporn and Weerakhun29 and Palma-Medel et al30 described a higher prevalence of dental disease in males.31 Girard21 also recorded a higher prevalence of odontogenic abscesses in males (82.5%; 33/40 animals). In contrast, Taylor et al19 treated 10 females and 3 males. In our study, a significantly higher prevalence was recorded in intact male rabbits in comparison with intact or spayed females (113 male and 87 female rabbits).

Diagnosis of odontogenic abscesses is based on clinical examination, intraoral examination under anesthesia, and radiography and CT. A combination of stomatoscopy and CT is the most beneficial for optimal diagnostics and treatment planning.21,27,3134 Knowledge of skull anatomy is essential for radiograph and CT evaluation and proper surgical approach. Each tooth and surrounding bone should be evaluated as periapical infection of only 1 tooth can be present without signs of osteomyelitis.21 A high incidence of infection of more than 3 teeth in a particular dental quadrant (63.3%, 131/207 abscesses) was found in the current study. This may lead to chronic infections as many rabbits were treated conservatively or surgically at other veterinary practices without a positive outcome and infection of the teeth that were not treated may have been subclinical.

Postoperative radiography is recommended in dog and cat dental surgical procedures,35 and these guidelines should also be followed in rabbit and other exotic mammal dental surgeries. Based on the authors' experience, it has an immediate impact on the proper removal of all the affected tissue (bone and teeth) and further wound healing.

It is postulated that rabbits have a higher incidence (4.8%) of perianesthetic mortality than dogs and cats.36 Another study37 recorded perianesthetic death in 7.37% of sick rabbits. In the present study, the mortality associated with anesthesia was 0.1%. A low perianesthetic mortality rate can be explained by thorough patient monitoring (visual, auscultation, and anesthetic monitoring) during the procedure and patient intubation.

Treatment of odontogenic abscesses and jaw osteomyelitis is difficult because both teeth and bone are involved and the purulent material produced cannot be drained easily.

As the purulent material in rabbits is predominantly caseous, radical debridement and removal are advised.26 Described surgical techniques include excision of the entire abscess, followed by either primary closure alone or with antibiotic-impregnated beads or marsupialization and packing of the surgical site with antibiotics, honey, or other solutions.2 Wound marsupialization and the extraoral approach are preferred by many clinicians as they allow for frequent postoperative debridement, application of antiseptics or other products to promote healing, and constant direct monitoring of healing by second intention until it is complete.24 In all 200 cases presented, the wound was debrided at each anesthetic event during the follow-up, and the potassium permanganate antiseptic solution, which also promotes healing, was applied. No abscess cavity flushing was performed, as flushing may be counterproductive, and bacteria may be translocated to other soft tissues and cause distant infections.25

Apart from selected case reports, there are only 2 studies18,19 that assess the treatment of odontogenic abscesses in rabbits using a wound-packing technique. The first study19 assessed 13 rabbits with follow-up for at least 6 months, and the second study18 assessed 10 rabbits with follow-up for 3 to 38 months. Using the wound-packing technique, minimal surgical debridement was used, avoiding extensive dissection of the abscess capsule from the skin. The abscess cavity was flushed with saline fluid and packed with gauze impregnated with various antibiotics with the skin sutured closed.18 This procedure was repeated weekly with the removal and evaluation of the old gauze, which was replaced with new gauze strips containing an appropriate antimicrobial agent. Treatment was discontinued when the abscess cavity was almost completely replaced by granulation tissue and no purulent material remained; the extraction of affected teeth was not performed unless they were mobile.18

In the case of odontogenic abscesses, follow-up is 1 of the main contributors to therapeutic success, as only regular wound reevaluation and debridement can result in the desired outcomes. In the present study,18 the mean wound healing time was approximately 40 days (39.7 ± 1.41 days). The end of the healing time was established as complete skin epithelization, so the wound itself closed a little earlier (Figure 1). Disease-free time following abscess resolution in this study was on average 29 months (range 4 months to 60 months), with the majority of patients still living.

Only early infection and pathology detection can result in the extraction of the affected tooth only, optimal occlusal trimming, and therefore better outcomes.23 In many cases, more than 1 tooth is affected, and extraction of these teeth is recommended.28 The eruption rate of teeth in rabbits is dependent on diet type.38,39 It seems that adaptation of teeth eruption is also related to the premolars and molars, which are not in occlusion, with their eruption being arrested or decelerated. In a study by Girard,21 all the teeth out of occlusion had arrested growth, with the location of other teeth in the affected jaw changing as a result of orthodontic movement. Based on the experience of the authors of the present study, teeth eruption seems to be predominantly arrested in older animals. In some cases, the elongation of teeth from the side opposite to the extraction was recorded and many animals exhibited other types of dental disease than infection in other dental arcades. For this reason, regular follow-up is again recommended, as well as the fact that the majority of affected rabbits already have some form of dental disease.

Systemic antibiotic treatment for a minimum of 2 to 3 weeks postsurgery is recommended but might require longer if the nidus of infection is not removed. The choice of antibiotics for the treatment of osteomyelitis (odontogenic abscesses) is based on cytological and microbiological findings as well as antibiotic susceptibility testing. Antimicrobial agents demonstrate variable bone penetration. However, agents with poor bone penetration can still achieve bone tissue concentrations above the minimum inhibitory concentration for target pathogens. Experimental studies40,41 performed in rabbits generally demonstrate excellent bone penetration by fluoroquinolones, and satisfactory bone concentrations are achieved by beta-lactams. Metronidazole is most active against gram-negative anaerobes, such as Bacteroides sp and Fusobacterium sp, whereas its activity against gram-positive anaerobes such as Peptostreptococcus sp and Clostridia sp is more variable. Another drug of choice may be azithromycin due to its relatively wide spectrum and good tolerance.20 Because of the toxicity of beta-lactams administered perorally, parenteral administration is the recommended route. There are several penicillins recommended for parenteral treatment of rabbits; however, there is limited evidence-based knowledge on their effective dosage and frequency of administration. Penicillin-G should be administered at the dosage of 60,000 IU/kg, q 12 h, to achieve proper antimicrobial levels.42 To the authors' knowledge, there is only 1 study43 with a penicillin/streptomycin combination, but with 10% mortality. Therefore, the dosage or frequency is only anecdotal. Multiresistant microbes were found in a study by Jekl et al,11 which included Escherichia coli, Enterobacter cloacae, Proteus vulgaris, Pseudomonas sp, and beta-hemolytic group G Streptococcus sp. Even though the risk of possible transmission of zoonotic pathogenic microbes is minimal, proper handling and a sterile surgical approach should be used in all cases of odontogenic abscesses in rabbits.

In cases where operative treatment of osteomyelitis is not feasible, suppressive oral antibiotic therapy has been reported as an effective treatment.1,19 Potential benefits from chronic antibiotic suppressive therapy exist; however, it is not an effective alternative to the surgical treatment of bone infection. Based on the authors' experience, such cases can be treated with analgesics and short-term (up to 3 weeks) antibiotics. Animal welfare needs to be evaluated regularly and if any signs of wasting become evident, euthanasia should be recommended.44

If indicated, patients should receive nutritional support in the form of syringe-fed critical care formula (Oxbow Critical Care, Emeraid Herbivore, Supreme Recovery, etc), parenteral fluid therapy, as well as pain management.45,46 Following dental treatment, nutrition should be adjusted to provide a high-quality and high-fiber diet (such as greens, grass hay with a combination of meadow and alfalfa hay, and fruit tree branches) and intake of sufficient amounts of nutrients by feeding a high-quality pelleted food. An optimal calcium-to-phosphorus ratio (about 1.5:1) should be provided in the diet.47 Multimodal and preemptive analgesia should be provided in all cases. Anesthetics with analgesic potency (low-dose ketamine and medetomidine), opioids (buprenorphine, fentanyl, methadone, and oxymorphone), and NSAIDS (meloxicam) and gabapentin should be used in combination. Combinations and type of postsurgical anesthetics are adjusted based on the presence of pain.48 Other supportive care may include administration of vitamin C, which stimulates wound healing,49 and osteogenetic drugs. However, its use in odontogenic abscess treatment needs to be experimentally proved.

The recurrence rate in this study from 200 pet rabbits with odontogenic abscesses was 8% (16/200 cases), showing a success rate of 92%. However, due to complications during the healing period, 16% of rabbits (32/200) need to be surgically treated again.

The limitations of the present study are associated with a partial referral practice, so the true prevalence of odontogenic abscesses is not exact. As many patients were referral cases or were referred during the chronic stage of the disease, more than 2 or 3 teeth were affected, and more radical surgeries need to be performed. The radical approach described in this study was also selected due to the personal previous negative experience with the wound-packing technique and that many referral cases were unsuccessfully treated by this technique (not included in the study period). Nevertheless, only clinical trials can be used to compare different techniques for the treatment of odontogenic abscesses. More comparable data for optimal technique selection in particular individual cases are needed, as apart from the present study, no more than 13 animals were treated.

The study's robustness lies in the fact that all the patients were treated surgically, follow-up examinations were performed in the same clinic, patients were examined using CT allowing for proper therapeutic planning and prognosis establishment, and all the patients underwent postoperative radiography or CT examination to follow the progression of healing.

The radical surgical technique with the extraction of all the infected teeth with the removal of all affected tissue and osteomyelitic bone and regular follow-up wound management is an effective method for the treatment of odontogenic abscesses with jaw osteomyelitis.

Acknowledgments

The authors thank the team of the Jekl & Hauptman Veterinary Clinic for taking care of the pet rabbits included in this study.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

This article was supported by a grant from the University of Veterinary Sciences Brno 2021ITA15.

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