Veterinary dentistry and oral surgery for geriatric patients

Geriatric veterinary patients have a variety of health care needs. Topping the list is the need for thorough physical and oral examinations. These evaluations, along with a thorough history, help veterinarians recognize existing conditions and alert them to potential problems. These issues need to be diagnosed, prioritized, and addressed in a timely fashion in order to optimize patient comfort, safety, and overall quality of life.

Many older patients also have oral, dental, and periodontal problems. These problems are frequently painful and, in some cases, create problems with food prehension or mastication. Treating these problems can dramatically improve geriatric patients' quality of life, and the clinical data clearly illustrate the benefits dental and oral surgery can provide for these pets.

Diagnosis

A problem-orientated approach to veterinary dentistry and oral medicine is helpful, especially in working with geriatric patients. Information from the signalment, history, physical exam, and a minimum database of blood work allows for problem identification. From there, fundamental diagnostic tests, such as dental radiography, and periodontal and dental probing, are used to refine the issue. While rhinoscopy can help access the respiratory tract for biopsy, advanced imaging techniques, particularly computed tomography (CT), and magnetic resonance imaging (MRI), can be especially helpful with diagnosis, establishing an accurate prognosis, and for treatment planning.

While the equipment needed for these procedures is not available to all veterinarians, clients often appreciate it when their veterinarians refer them to a facility where the tests are available. Diagnosis should precede treatment planning and definitive therapy.

Treatment planning

Understanding the client's priorities is fundamental to treatment planning. For each problem, treatments should be developed with direct client consultation. Each potential diagnosis, the nature of any problems, all treatment options (with cost estimates), and prognosis are discussed. The impact of the problem, diagnostic procedures, and definitive treatments on the patient's quality of life, are generally important to clients. Elimination or minimization of pain is always prioritized.

The practice of treating the treatable focuses on prognosis with regard to geriatric patients. As an example, I frequently perform an incisional biopsy to establish the diagnosis of an oral mass. For malignant tumors, a CT scan is performed before definitive surgery to determine the extent of the tumor and whether the neoplasm is resectable.

Obtaining informed consent allows clear communication between the client and the operator. Risks associated with treatment plans and benefits for the patient are discussed.

Benefits

*The following cases illustrate the benefits of treatment for senior dogs.

CASE 1: Boots, a 16-year-old male domestic shorthair cat with reduced appetite for approximately three weeks, is gradually losing weight. Boots acts interested in food. He eats small amounts and runs from the food dish. He frequently drops food and paws at his face. The client is worried about Boots' poor quality of life and has considered euthanasia.

Photo 1: Resorptive lesion on the lower right canine tooth

DIAGNOSTIC TESTING RESULTS

• BUN 25 mg/dL and Creatinine 1.0 mg/dL.

• ALT 180 U/L (Normal=12-130) and ALKP 222U/L (Normal=14-111).

• TT4 5.7mcg/dL (Normal=1.9-4.8).

• All other blood work results were within normal limits.

• Heart rate 169 beats /minute.

• ECG and Doppler blood pressure were normal.

• Oral examination revealed painful tooth resorption (photo 1).

• Dental radiographs demonstrate tooth resorption (photo 2).

• Dental probing demonstrated enamel defects in the crowns of multiple teeth (photo 3).

• Periodontal probing was normal.

DIAGNOSIS: Tooth resorption.

Photo 2: Dental radiograph demonstrating tooth resorption

TREATMENT PLAN: Dental extraction of teeth with tooth resorption to eliminate pain.

RESULT: Boots returned to normal eating within 24 hours of having multiple dental extractions.

Photo 3: Periodontal probe demonstrates tooth resorption

COMMENT: The owners were worried about having Boots undergo a procedure with little benefit. They decided that Boots' quality of life needed to improve, or euthanasia would be needed. They were tremendously grateful for having a dental consultation to better understand the diagnosis, prognosis, and treatment plan.

CASE 2: Maxine, a 13-year-old mixed breed, has a chronic right suborbital swelling. Previously both upper fourth premolar teeth were extracted. The original operator was uncertain whether the teeth were completely extracted, and dental radiographs were not available to establish this diagnosis. Immediately after the initial surgery, the swelling reduced by approximately 70 percent. Two weeks after therapy, the swelling doubled in size.

DIAGNOSTIC TESTING RESULTS

• Blood work results were within normal limits.

• Dental radiographs revealed retained roots (photo 4—two retained roots, photo 5—retained roots removed, and photo 6—retained root on right side with right facial swelling).

• Periodontal probing was normal.

DIAGNOSIS: Retained tooth roots.

Photo 4: Two roots retained on the left side

TREATMENT PLAN: Treatment plan: Retained roots were removed on the left side (photo 5) and an unusual tissue was submitted for histology from the right side. The retained root was also removed from the right side.

DIAGNOSIS: Histologic examination revealed squamous cell carcinoma.

Photo 5: X-ray confirms retained roots in photo #4 were removed

RESULT: Maxine has been referred to a veterinary medical oncologist for further treatment planning.

COMMENT: Not all suborbital swellings are related to tooth root disease. Dental radiographs should precede treatment planning. The presence of retained root tips does not necessarily represent the cause of the suborbital swelling. Periapical pathology was not evident in this case. Neoplasia should always be considered as a potential cause of facial swellings in geriatric patients. Dental extraction was of no benefit for this patient.

CASE 3: Dakota, a 14-year-old Siberian husky, fractured its left upper canine tooth 30 minutes before presentation. The pulp was exposed and the tooth was bleeding.

DIAGNOSTIC TESTING RESULTS

• Dakota's blood work was normal. Dakota had a grade 5 (of 6) systolic heart murmur and has been doing well on enalapril and furosemide for the last 15 months.

• Dental radiographs revealed a vital tooth (photo 7).

DIAGNOSIS: Vital tooth was fractured with pulp exposure.

Photo 6: Retained root on the right side. The face was swollen.

TREATMENT PLAN: Definitive therapy was to be performed. Options were to provide vital pulpotomy therapy, root canal therapy, or dental extraction. Root canal therapy is more predictable than vital pulpotomy therapy on a long-term basis. The owner elected vital pulpotomy therapy to reduce the duration of anesthesia and cost. The short duration of pulp exposure made this option a reasonable choice. A third option was dental extraction. In this specific case the owner did not want to have the tooth extracted, as the tooth was ankylosed and may have been difficult to extract.

RESULT: Dakota had a vital pulpotomy procedure performed. He was doing well immediately after the procedure, and he retained this functional tooth.

COMMENT: Dental radiographs were fundamental to treatment planning. The first determination was whether the tooth was vital. This is a requirement for a vital pulpotomy procedure. If the tooth was nonvital, root canal therapy or dental extraction would have been the only treatment options. The radiographs also helped in planning dental extraction. Tooth root ankylosis is diagnosed when there is a partial or total loss of periodontal ligament around the tooth. Teeth with ankylosis can be difficult to extract with a greater risk for complications.

Successful vital pulp therapy is dependant on technique and time sensitivity. In this specific case, the early presentation of the patient improved the prognosis for vital pulp therapy. In older patients, the blood supply is reduced from dentin development. While reduced blood supply may adversely affect the long term prognosis, the various considerations were discussed with the client. If the tooth were to become nonvital (dead), root canal therapy or extraction could be performed.

Photo 7: Fractured vital tooth with pulp exposure and ankylosis

CASE 4: Joey, a 12-year-old yellow Labrador retriever, had discolored upper canine teeth (photo 8). The left tooth was fractured and had a black discoloration over the central pulp canal (photo 9). Joey demonstrated no discomfort when chewing hard food. He would use both teeth for grasping objects. Joey had multiple worn teeth from chewing hard objects over several years.

DIAGNOSTIC TESTING RESULTS

• Dental radiographs revealed no periapical changes of the discolored and worn teeth. The left tooth had an extremely wide root canal compared to the other teeth. This suggested the tooth was nonvital. Nonvital teeth serve as a bacterial reservoir and can result in systemic spread of bacteria.

• Dental probing revealed no pulp exposure.

• Periodontal probing demonstrated no significant lesions.

DIAGNOSIS: Right canine was discolored. The left canine was discolored and nonvital. Dental radiographs were used to help evaluate for evidence of periapical changes.

TREATMENT PLAN: Treatment options were root canal therapy or dental extraction of both canine teeth or the left upper canine could be treated and the right upper canine tooth monitored on a six-month basis.

Photo 8: Discolored upper left canine tooth

TREATMENT PERFORMED: Treatment was root canal therapy of the left upper canine tooth (photo 10).

RESULT: Joey experienced no problems from root canal therapy.

COMMENT: To minimize cost, the owner elected to monitor the right upper canine periodically using dental radiographs. The endodontically treated tooth would also be monitored during the same anesthesia period.

Photo 9: Fractured upper right canine tooth

Animals with discolored and severely worn teeth need full mouth dental radiographs for a complete dental evaluation. Many discolored teeth are nonvital. Patients that have chewed hard objects over a long time period may have developed tertiary (reparative) dentin. These teeth may not require treatment, but decisions must be based on dental radiographs.

Photo 10: Root canal therapy of left upper canine tooth

CASE 5: Marla, a 9-year-old, had an oral mass on the right mandible. The histologic diagnosis was osteosarcoma. The patient was showing no signs of discomfort; however, the mass was large and expansive.

DIAGNOSTIC TESTING RESULTS

• Blood work and urinalysis results were within normal limits.

• Dental radiographs revealed severe mandibular destruction.

• CT scan was performed to help determine that the mass was resectable and whether there was evidence of lymphatic or pulmonary metastatic disease. The CT scan demonstrated no metastatic disease and the tumor appeared contained within the right mandible.

DIAGNOSIS: Osteosarcoma with no evidence of metastatic disease.

TREATMENT PLAN: A hemimandibulectomy was performed on the affected side and histologic examination confirmed complete excision of the tumor.

RESULT: The owner was very pleased with the decision for hemimandibulectomy. Marla showed no evidence of postoperative pain or swelling. Her tongue protrudes from her mouth on the right side, but this was predicted and is very acceptable to the owners.

Marla was eating very well within 24 hours of the surgery. The owner has reported that Marla is back to playful activity within a week after the surgery.

COMMENT: Patients that require hemimandibulectomies or mandibulectomies typically experience an immediate improvement in their quality of life. For Marla, the osteosarcoma caused substantial bone destruction and was definitely painful. Immediately before the surgery and after the hemimandibulectomy, the owner recognized that Marla had been painful. Pain recognition is very difficult in veterinary patients, and possibly more difficult in older patients with multiple chronic problems.

CASE 6: Tiny, an 11-year-old female Great Pyrenees, presented with a moderate right mandibular swelling and severe pain. Tiny seemed particularly painful when attempting to chew food. She would chew primarily on the left side, and food would fall out of the mouth on the right side.

DIAGNOSTIC TESTING RESULTS

• Blood work and urinalysis results were within normal limits.

• An oral exam was not possible due to the degree of patient discomfort. Under anesthesia, a severe periodontal defect was evident. The local tissue appeared discolored and had a tremendous malodor.

• Dental radiograph revealed a poorly developed tooth with a wide root canal system.

• Periodontal probing revealed deep 8 to 12 mm periodontal defect.

DIAGNOSIS: Severe periodontal defect, stage 4 (of 4) periodontal disease with a nonvital tooth.

TREATMENT PLAN: Dental extraction to alleviate pain and stop further local destruction.

RESULT: Immediate improvement in eating and return to playful activity.

COMMENT: Periodontal disease is an infectious, inflammatory, and destructive process. Pain is often associated with periodontal disease. Although this patient presented as having an acute problem, she had an unusual chronic disease. Treatment was very rewarding for the patient and owner.

These oral surgery and dental cases illustrate the need to fully evaluate the geriatric patient and to clearly understand the client's priorities for their companions.

Prioritization of concurrent problems is important to optimize patient comfort, safety, and quality of life. Accurate diagnosis allows for appropriate treatment planning based on the patients' and clients' needs. Failure to establish an accurate diagnosis can lead to inappropriate therapy. Advanced imaging techniques can be utilized to help with the diagnosis, to better understand the prognosis, and to determine whether oral surgery is feasible.

Treating the treatable problems is not always logical, as geriatric patients sometimes have treatable conditions that may not significantly improve the patient's quality of life. Some nonpainful conditions may be monitored using periodic dental radiographs.

Dental problems are often painful and may create problems with food prehension or mastication. These conditions should be treated because such treatments can dramatically improve the quality of life for these animals.

Dr. Kressin operates the Animal Dental Center in Oshkosh, Wis. He is a diplomate of the American Veterinary Dental College and provides a conforming residency recognized by the American Veterinary Dental College.