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TUGAS MATA KULIAH

ILMU BEDAH KHUSUS

HALAMAN JUDUL

TEKNIK OPERASI EKSTRAKSI DAN SCALING GIGI

KELAS: B

I Gede Hendra Prasetya Wicaksana 1409005005

I Putu Werdikta Jayantika 1409005008

A. A. Gede Oka Wijaya 1409005026

I Made Adistanaya 1409005071

Luh Putu Pradnya Swari 1409005083

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA

DENPASAR

2017
RINGKASAN

Penyakit periodontal sangat sering dihadapi oleh dokter hewan praktisi, hal
tersebut membuat klien menanyakan penyakit periodontal pada hewan
kesayangan mereka. Faktor yang menyebabkan timbulnya penyakit
periodontal adalah kebiasaan menggigit, grooming, status kesehatan,
perawatan di rumah, bakteri yang aktif di ruang mulut, serta jenis pakan
yang diberikan. Penyakit periodontal dapat menyebabkan kualitas hidup
hewan berkurang. Penyakit periodontal juga dapat menyebabkan hewan
mengalami kesulitan makan, bau mulut, dan kesulitan membersihkan
dirinya (grooming). Penyakit periodontal dapat menyebabkan penyakit
sistemik seperti komplikasi kardiovaskular, rheumatoid arthritis, gangguan
kehamilan dan artherosclerosis. Penanganan penyakit periodontal yang
utama adalah mengurangi mikroba patogen. Tindakan yang dilakukan
untuk mengurangi mikroba antara lain scaling, root planning. Penanganan
pada penyakit gigi hewan yang umum dilakukan adalah ekstraksi dan
scaling gigi. Ekstraksi gigi merupakan pencabutan gigi dari soketnya pada
tulang alveolar dan scaling gigi adalah proses pembersihan karang gigi.

Kata kunci : ekstraksi, gigi, periodontal, scaling.

SUMMARY

Periodontal disease is very often encountered by veterinarian practitioners, it


makes clients ask periodontal diseases in their pets. Factors that cause
periodontal disease are habit of biting, grooming, health status, home care,
active bacteria in the mouth space, as well as the type of feed given.
Periodontal disease can lead to reduced quality of animal life. Periodontal
disease can also cause animals to have difficulty eating, bad breath, and
difficulty cleaning themselves (grooming). Periodontal disease can lead to
systemic diseases such as cardiovascular complications, rheumatoid arthritis,
pregnancy disorders and artherosclerosis. Handling of major periodontal
diseases is to reduce pathogenic microbes. Actions taken to reduce microbes
include scaling, root planning. Handling of common animal dental diseases is
extraction and scaling of teeth. Tooth extraction is the tooth extraction from
its socket on the alveolar bone and the dental scaling is the process of
cleaning the tartar.
Key words: extraction, tooth, periodontal, scaling.

ii
KATA PENGANTAR

Puji syukur penulis panjatkan kepada Tuhan Yang Maha Esa karena atas
berkat rahmat-Nya penulis dapat menyelesaikan tugas paper Ilmu Bedah Khusus
Veteriner yang berjudul Teknik Operasi Ekstraksi dan Scaling Gigi.

Segala kritik dan saran sangat penulis harapkan demi kebaikan dari tugas ini.
Terimakasih kepada dosen pengampu yang memberikan materi pada saat perkuliahan
dan praktikum, teman kelompok yang sudah banyak membantu dalam proses
pengerjaan paper ini. Dan tak lupa penulis mengucapkan banyak terima kasih kepada
semua pihak yang telah membantu penulis.

Denpasar, 12 Oktober 2017

Penulis

iii
DAFTAR ISI
HALAMAN JUDUL ................................................................................................. i
RINGKASAN .......................................................................................................... ii
KATA PENGANTAR ............................................................................................. iii
DAFTAR ISI ........................................................................................................... iv
DAFTAR GAMBAR ............................................................................................... v
DAFTAR LAMPIRAN ........................................................................................... vi
BAB I PENDAHULUAN......................................................................................... 1
1.1 Latar Belakang ..................................................................................... 1
1.2 Rumusan Masalah ................................................................................ 2
BAB II TUJUAN DAN MANFAAT TULISAN ....................................................... 3
2.1 Tujuan Tulisan .................................................................................... 3
2.2 Manfaat Tulisan .................................................................................. 3
BAB III TINJAUAN PUSTAKA ............................................................................. 4
3.1 Anatomi Gigi .................................................................................... 4
3.2 Penyakit Pada Gigi ............................................................................ 6
3.3 Ekstraksi Gigi.................................................................................... 6
3.4 Scaling Gigi ...................................................................................... 7
BAB IV PEMBAHASAN ........................................................................................ 8
4.1 Managemet Pre-Operasi ....................................................................... 8
4.2 Tindakan Anestesi................................................................................ 9
4.3 Teknik Operasi .................................................................................... 9
4.3.1 Ekstraksi Gigi ........................................................................ 9
4.3.2 Scaling Gigi ......................................................................... 12
4.4 Management Pasca Operasi................................................................ 15
BAB V SIMPULAN DAN SARAN ....................................................................... 16
5.1 Simpulan ........................................................................................... 16
5.2 Saran ................................................................................................. 16
DAFTAR PUSTAKA............................................................................................. 17
LAMPIRAN ........................................................................................................... 18

iv
DAFTAR GAMBAR

Gambar 1 ........................................................................................................ 4
Gambar 2 ........................................................................................................ 5
Gambar 3 ........................................................................................................ 5
Gambar 4 ........................................................................................................ 10
Gambar 5 ........................................................................................................ 10
Gambar 6 ........................................................................................................ 10
Gambar 7 ........................................................................................................ 11
Gambar 8 ........................................................................................................ 11
Gambar 9 ........................................................................................................ 12
Gambar 10 ...................................................................................................... 12
Gambar 11 ...................................................................................................... 13
Gambar 12 ...................................................................................................... 13
Gambar 13 ...................................................................................................... 14
Gambar 14 ...................................................................................................... 14
Gambar 15 ...................................................................................................... 15

v
DAFTAR LAMPIRAN

Prevelence of dental disorders in pet dogs

Applied Feline Oral Anatomy And Tooth Extraction Techniques

vi
BAB I
PENDAHULUAN
1.1 Latar Belakang

Indonesia sebagai negara berkembang membuat pola hidup masyarakat


mengikuti gaya di negara maju. Salah satu gaya hidup yang diikuti adalah memiliki
hewan kesayangan. Kucing dan anjing merupakan hewan peliharaan yang umum
dimiliki oleh masyarakat. yang banyak digemari oleh banyak orang.

Manfaat memelihara anjing dan kucing dapat terasa secara fisik dan mental.
Anjing dan kucing merupakan hewan yang dekat dengan manusia sehingga
perawatan harus selalu diperhatikan, Perawatan yang kurang baik dapat
menyebabkan penyakit. Salah satu penyakit yang sering diderita anjing adalah
penyakit periodontal.

Penyakit periodontal sangat sering dihadapi oleh dokter hewan praktisi, hal
tersebut membuat klien menanyakan penyakit periodontal pada hewan kesayangan
mereka. Faktor yang menyebabkan timbulnya penyakit periodontal adalah kebiasaan
menggigit, grooming, status kesehatan, perawatan di rumah, bakteri yang aktif di
ruang mulut, serta jenis pakan yang diberikan (Gawor et al. 2006).

Penyakit periodontal dapat menyebabkan kualitas hidup hewan berkurang.


Penyakit periodontal juga dapat menyebabkan hewan mengalami kesulitan makan,
bau mulut, dan kesulitan membersihkan dirinya (grooming). Penyakit periodontal
dapat menyebabkan penyakit sistemik seperti komplikasi kardiovaskular, rheumatoid
arthritis, gangguan kehamilan dan artherosclerosis (Kortegaard et al. 2014).

Penanganan penyakit periodontal yang utama adalah mengurangi mikroba


patogen. Tindakan yang dilakukan untuk mengurangi mikroba antara lain scaling,
root planning (Fernandes et al. 2010). Penanganan pada penyakit gigi hewan yang
umum dilakukan adalah ekstraksi dan scaling gigi. Ekstraksi gigi merupakan
pencabutan gigi dari soketnya pada tulang alveolar dan scaling gigi adalah proses
pembersihan karang gigi.

1
1.2 Rumusan Masalah

1.1.1. Apa yang dimaksud dengan ekstraksi dan scaling gigi ?


1.1.2. Bagaimana manajemen pre operasi ekstraksi dan scaling gigi ?
1.1.3. Bagaimana teknik operasi ekstraksi dan scling gigi ?
1.1.4. Bagaimana manajemen pasca operasi ekstraksi dan scaling gigi ?

2
BAB II
TUJUAN DAN MANFAAT TULISAN

2.1 Tujuan Tulisan

1. Untuk memahami apa yang dimaksud dengan ekstraksi dan scaling gigi
2. Untuk mengetahui manajemen pre operasi ekstraksi dan scaling gigi
3. Untuk memahami teknik operasi ekstraksi dan scaling gigi
4. Untuk mengetahui manajemen pasca operasi ekstraksi dan scaling gigi

2.2 Manfaat Tulisan

Penulis berharap melalui paper yang kami yang buat berjudul Teknik
Operasi Ekstraksi dan Scaling Gigi dapat memberikan informasi dan
pengetahuan kepada pembaca, sehingga pembaca dapat mengetahui definisi
dan bagaimana prosedur dan teknik ekstraksi dan scaling gigi, yang baik dan
benar sehingga dapat menerapkannya dalam prakteknya.

3
BAB III
TINJAUAN PUSTAKA

3.1 Anatomi Gigi

Struktur primer dari ruang mulut terdiri atas gigi, gusi, lidah, palatum durum,
dan palatum nuchae. Setiap spesies memiliki formula gigi yang berbeda. Formula
gigi adalah jumlah dan tipe dari gigi pada mulut yang normal. Mamalia umumnya
memiliki dua jenis gigi yaitu, gigi primer atau deciduous dan gigi permanen. Kucing
memiliki empat tipe gigi yang terdiri dari gigi incisivus, caninus, premolar dan
molar (Perrone, 2013). Deciduous anjing sebanyak 28 buah (12 incisor, 4 caninus, 8
premolar dan 4 molar), sedangkan gigi permanen sebanyak 42 buah (12 incisor, 4
caninus, 16 premolar dan 10 molar) (Pieri e al. 2012).

Gambar 1 Diagram Gigi Kucing (Crossley 2002). Gigi 101 109 adalah gigi pada
maxilla kanan, gigi 201 209 adalah gigi pada maxilla kiri. Gigi 301 -309 adalah
gigi pada mandibular kiri dan gigi 401 409 adalah gigi pada mandibular kanan

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Gambar 2. Diagram Gigi Anjing (Crossley 2002)

Struktur anatomi gigi terdiri atas crown, enamel, cementum, dentin, pulpa,
dan akar. Crown adalah bagian gigi yang terletak di atas gusi dan akar gigi adalah
bagian gigi yang berada di bawah gusi. Enamel adalah bagian yang melindungi
crown dan cementum adalah bagian yang melindungi akar gigi. Pulpa terdiri atas
jaringan ikat, nervus, dan pembuluh darah (Perrone, 2013).

Gambar 3. Struktur anatomi gigi

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3.2 Penyakit Pada Gigi

Penyakit gigi yang umum terjadi pada hewan peliharaan adalah:


Dental calculus (tartar). Tartar berkembang membentuk calculus atau karang
gigi, menumpuk di antara gigi dan gusi dan merangsang perkembangan
bakteri di daerah tersebut.
Radang gusi, tumpukan tartar dapat mengiritasi gusi dan menyebabkan
peradangan pada gusi. Radang gusi terlihat dari gusi yang berwarna merah
tua di daerah perbatasan dengan gigi.
Penyakit periodontal. Periodontal berasal dari dua kata yunani yaitu Peri yang
berarti pinggiran atau sekitar, dan dontal yang berarti gigi. Penyakit
periodontal adalah gangguan pada gigi dan daerah sekitarnya yang biasanya
disertai peradangan. Penyakit ini dapat mengganggu jaringan penahan yang
terdapat disekitar gigi, akibatnya gigi menjadi goyah dan mudah lepas.
Fraktur gigi, yaitu suatu keadaan dimana hilangnya atau lepasnya fragmen
dari satu gigi lengkap yang biasanya disebabkan oleh trauma atau benturan.

3.3 Ekstraksi Gigi

Pencabutan gigi (Ekstraksi) merupakan tindakan bedah minor yang sering


dilakukan dan menimbulkan luka pada soket gigi dan tulang alveolar. Proses
penyembuhan tulang alveolar pasca pencabutan gigi merupakan hal yang penting
untuk perawatan dental, terutama jika setelah pencabutan gigi akan dilakukan
perawatan lanjutan seperti pemasangan protesa (implan atau gigi tiruan jembatan)
dan perawatan ortodontik (Dharmaet al., 2010; Haghighat et al., 2011; Zhanget al.,
2012).

Meskipun tujuan utama dari dentistry harus pemeliharaan gigi, untuk alasan
yang berbeda-beda, pencabutan gigi mungkin pilihan terbaik dari masing-masing
yang terkena masalah klinis. Selain itu, pencabutan gigi adalah jauh prosedur bedah
mulut yang paling umum dilakukan di manusia (Batenburg et al., 2000) dan hewan
domestik seperti kuda, anjing, kucing, Lagomorpha (kelinci) dan tikus (Gaughan,
1998; Bellows, 2004).

6
Indikasi umum untuk menghilangkan gigi cukup mirip dalam semua spesies
dan termasuk pulpitis atau infeksi periapikal yang disebabkan oleh kerusakan gigi
atau terbukanya pulpa traumatis, penyakit periodontal yang parah (Scheels and
Howard, 1993; Legendre, 1994; Dixon, 1997a; Wiggs and Lobprise, 1997a; Sullivan,
1999; Alsheneifi and Hughes, 2001; Richards et al., 2005).

3.4 Scaling Gigi

Scaling atau pembersihan karang gigi adalah proses untuk menghilangkan


atau membersihkan kalkulus dan plak yang menumpuk pada gigi. Seiring perjalanan
waktu, plak yang menumpuk akan dapat menyebabkan gusi menjadi meradang dan
berdarah. Jika tidak dibersihkan, radang ini akan mengarah pada tahap awal penyakit
gusi yang disebut gingivitis.

7
BAB IV
PEMBAHASAN

4.1 Managemet Pre-Operasi

Management pre operasi yang perlu dipersiapkan pada operasi ektraksi dan
scaling gigi adalah :

1. Persiapan Alat dan Bahan


Alat yang digunakan adalah termometer, stetoskop, timbangan, grafik
gigi untuk kucing, endotracheal tube ukuran 2 mm, IV catheter 24G, reader
kimia darah VetScan versi 2, hematology analyzer VetScan HM 5, tabung
vakum dengan antikoagulan heparin, dan tabung vakum tanpa antikoagulan,
alat-alat dental scaling dan dental extraction meliputi elevator, extraction
forceps, probe, ultrasonic scaler, sharp scaler, bor gigi, polisher, curette,
hook explorer, dan 3-ways syringes (Holmstrom et al. 2013a).
Bahan yang digunakan adalah atropine sulfat, ketamine, xylazine,
anastetikum gas isofluran, pet gel, chlorhexidine rinse, fluoride, NaCl,
benang polyglycoli acid 4/0 dan jarum regular taper point circle

2. Pemeriksaan Fisik Hewan


Hewan diperiksa keadaan fisiknya. Pemeriksaan ini bertujuan untuk
mengetahui keadaan fisik hewan, perubahan yang terjadi dan evaluasi
preanestesi. Pemeriksaan fisik meliputi pengukuran berat badan
menggunakan timbangan, pengukuran suhu tubuh hewan menggunakan
termometer, menghitung frekuensi napas dan frekuensi jantung per menit
menggunakan stetoskop.

3. Pemeriksaan Keadaan Gigi


Gigi hewan diperiksa satu persatu dan hasilnya dicatat pada diagram
gigi Pemeriksaan dimulai dari mencatat gigi yang telah hilang dilanjutkan
dengan penilaian calculus pada masing-masing permukaan gigi. Pemeriksaan
selanjutnya adalah pemeriksaan indeks gingivitis dan sulcus gingivitis. Sulcus

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gingivitis diperiksa dengan bantuan probe. Gingival resection diperiksa
dengan bantuan probe. Furcation diperiksa dengan bantuan hook explorer.

4.2 Tindakan Anestesi

Anestesi dilakukan dengan pemberian premedikasi terlebih dahulu melalui


rute subkutan. Premedikasi yang digunakan adalah atropin sulfat. Atropin sulfat
adalah sediaan anti kolinergik. Atropin sulfat digunakan untuk mencegah terjadinya
bradikardia. Kombinasi ketamine dan xylazine diberikan untuk anestesi umum
melalui rute intravena. Kombinasi ketamine dan xylazine digunakan karena ketamine
memiliki efek samping terjadinya kekakuan otot dan xylazine merupakan sediaan
yang dapat merelaksasikan otot

Saat hewan mulai hilang kesadarannya, endotracheal tube ukuran 2 mm


dipasang pada hewan. Pemasangan endotracheal tube dibantu dengan laryngoscope
untuk melihat posisi epiglotis. Tanda bahwa endotracheal tube masuk pada saluran
pernapasan adalah hewan sedikit tersedak dan keluar udara melalui lubang
endotracheal tube. Isofluran sebagai anestesi per inhalasi diberikan setelah
endotracheal tube terpasang.

Maintenance isofluran dilakukan sepanjang proses operasi penyakit


periodontal. Tujuan dari pemasangan endotracheal tube adalah untuk mempermudah
proses maintenance anestesi secara per inhalasi. Sediaan anestesi per inhalasi yang
digunakan adalah isofluran. Isofluran digunakan karena induksinya yang halus dan
cepat, pemulihannya yang cepat, dan kelarutannya dalam darah rendah (Capey
2007).

4.3 Teknik Operasi

4.3.1 Ekstraksi Gigi

Contoh teknik operasi ekstrasi gigi sebagai berikut. Pasien merupakan seekor
anjing Corgi berusia empat tahun yang mengalami fraktur premolar keempat disertai
dengan adanya tartar. Pasien diperiksa kondisi fisik secara umum lalu dianastesi
kemudian pasien diletakan di meja operasi dengan posisi dorsal recumbency, lalu
masukkan endotracheal tube ke mulut pasien.

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Gambar 4. Fraktur premolar keempat disertai dengan adanya tartar

Gusi diinsisi terlebih dahulu dari depan ke belakang untuk membuat suatu
penutup yang dapat dijahit setelah gigi diekstraksi.

Gambar 5. Gusi diinsisi

Periosteal elevator digunakan untuk memisahkan gusi dengan tulang rahang.


Hal ini dilakukan untuk lebih mudah mengakses akar gigi dan mempertahankan
kualitas penutup saat proses penyembuhan.

Gambar 6. Pemisahan gusi dengan tulang rahang

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Gigi premolar keempat merupakan gigi terbesar pada anjing, sehingga harus
dibelah terlebih dahulu untuk memudahkan proses pencabutan serta meminimalisir
kerusakan pada tulang rahang dan gusi. Saat gigi sudah terbelah, setiap potong gigi
beserta akarnya dapat dilepas dari gusi dan rongga gigi dengan menggunakan
extraction forcep.

Gambar 7. Pencabutan gigi

Setelah gigi dicabut, pediatric drill digunakan untuk menghaluskan tepi


alveolar (rongga gigi).

Gambar 8. Penghalusan tepi alveolar dengan pediatric drill

11
Gusi dijahit dengan menggunakan benang monocryl ukuran 4.0 dengan pola
jahitan simple interrupted.

Gambar 9. Penjahitan gusi


Setelah gusi dijahit, hal terakhir yang dilakukan adalah mebersihkan sisa
sisa tartar yang terdapat di seluruh gigi.

Gambar 10. Kondisi mulut pasien setelah dioperasi

4.3.2 Scaling Gigi

Pasien merupakan seekor anjing Labrador berusia tiga tahun yang mengalami
tartar dan plak diseluruh gigi. Pasien diperiksa kondisi fisiknya secara umum lalu
dianastesi kemudian pasien diletakan di meja operasi dengan posisi dorsal
recumbency, lalu masukkan endotracheal tube ke mulut pasien. Setelah pasien
teranastesi, dilakukan pemeriksaan secara menyeluruh terhadap gigi pasien.

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Gambar 11. Pemeriksaan gigi pasien

Gambar 12. Pemeriksaan gigi pasien dengan dental X-Ray

Plak dan tartar pada bagian bawah dan atas gusi serta di permukaan dan
bagian belakang gigi dibersihkan dengan menggunakan alat dental scaler.

13
Gambar 13. Pembersihan plak dan tartar menggunakan dental scaler

Setelah tartar dan plak pada gigi dibersihkan, gigi dipoles untuk
membersihkan plak residual dan menghaluskan permukaan gigi. Hal terakhir yang
dilakukan adalah penambahan fluoride pada gigi pasien sehingga gigi pasien lebih
kuat dan tidak cepat berlubang.

Gambar 14. Pemolesan gigi

14
Gambar 15. Penambahan fluoride

4.4 Management Pasca Operasi

Setelah operasi, hal hal yang perlu dilakukan adalah memberikan obat
analgesia serta antiseptic oral gel (zinc ascorbate) dapat diberikan selama lima
sampai tujuh hari untuk mengurangi rasa sakit serta mencegah infeksi. Pakan yang
diberikanpun harus pakan yang konsistensinya lembut, hal ini dapat dilakukan
selama dua minggu hingga kondisi pasien kembali seperti semula, Jika terjadi
perdarahan pada mulut, pemilik harus segera membawa pasien ke dokter hewan.

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BAB V
SIMPULAN DAN SARAN

5.1 Simpulan

Pencabutan gigi (Ekstraksi) merupakan tindakan bedah minor yang sering


dilakukan dan menimbulkan luka pada soket gigi dan tulang alveolar. Sedangkan
Scaling atau pembersihan karang gigi adalah proses untuk menghilangkan atau
membersihkan kalkulus dan plak yang menumpuk pada gigi. Seiring perjalanan
waktu, plak yang menumpuk akan dapat menyebabkan gusi menjadi meradang dan
berdarah. Sebelaum dilakukan ekstraksi maupun Scaling dilakukan management pre
operasi, yang perlu dipersiapkan pada operasi ektraksi dan scaling gigi adalah
dengan pemeriksaan fisik dan gigi hewan, serta persiapan alat dan bahan. Kemudian
dilakukan Anestesi dengan pemberian premedikasi terlebih dahulu melalui rute
subkutan. Premedikasi yang digunakan adalah atropin sulfat. Teknik operasi yaitu
Ekstraksi dan Gigi Scaling Gigi. Setelah operasi, hal hal yang perlu dilakukan
adalah memberikan obat analgesia serta antiseptic oral gel (zinc ascorbate) dapat
diberikan selama lima sampai tujuh hari untuk mengurangi rasa sakit serta mencegah
infeksi.

5.2 Saran

Apabila hewan peliharaan pembaca mengalami tanda tanda klinis penyakit


gigi seperti bau mulut, kurang nafsu makan, gigi patah atau lepas, perdarahan dari
mulut, gigi berubah warna, serta pembengkakan di sekitar daerah mulut, segera
konsultasikan ke dokter hewan terdekat untuk mengetahui terapi lebih lanjut.
Pemberian pakan hewan yang sesuai juga dapat dilakukan untuk mengurangi resiko
terbentuk plak atau tartar, serta menggosok gigi hewan dengan pasta gigi khusus
hewan sehari sekali dapat dilakukan untuk menjaga kesehatan gigi hewan sehingga
terhindar dari penyakit.

16
DAFTAR PUSTAKA

Capey S. 2007. The Comprehensive Pharmacology. Philadelphia (US): Elsevier


Science. hlm 14.

Fernandes LA, Martins TM, Almeida JMD, Nagata MJH, Theodoro LH, Garcia VG,
Bosco AF. 2010. Experimental periodontal disease treatment by subgingival
irrigation with tetracycline hydrochloride in rats. J Appl Oral Science.
18(6):635-40. doi: 10.1590/S1678-77572010000600017.

Gawor JP, Reiter AM, Jodkowska K, Kurski G, Wojtacki MP, Kurek A. 2006.
Influence of diet on oral health in cats and dogs. J Nutrition. 136(7):2021
2023.

Kortegaard HE, Eriksen T, Baelum V. 2014. Screening for periodontal disease


inresearch dogs - a methodology study. ActaVetScand.
56(1):77.Doi:10.1186/s13028-014-0077-8.

Kyllar M, Witter K. 2005. Prevelence of dental disorders in pet dogs. Original Paper
Vet. Med 50, 11:496-505

Perrone JR. 2013. Small Animal Dental Procedures for Veterinary Technicians and
Nurses. Iowa (US): J Wiley. hlm 4, 5, 14, 15, 25, 26, 96, 97.
.
Reiter, Alexander M and Maria M Soltero-Rivera. 2014.Applied Feline Oral
Anatomy And Tooth Extraction Techniques. Journal of Feline Medicine and
Surgery.16, 900913

17
LAMPIRAN

18
Original Paper Vet. Med. Czech, 50, 2005 (11): 496505

Prevalence of dental disorders in pet dogs


M. Kyllar1, K. Witter2
1
Institute of Anatomy, Histology and Embryology, Faculty of Veterinary Medicine,
University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
2
Institute of Histology and Embryology, Department of Pathobiology, University of Veterinary
Medicine, Vienna, Austria

ABSTRACT: Oral disorders of the dog represent for veterinarians a medical challenge and an important field of
interest from the economical point of view. Although many epidemiological studies on dental diseases in beagles
bred under controlled conditions have been realized, information on frequency of these alterations in populations
of pet dogs, especially in Central Europe, is far from complete. The aim of our study was to assess the prevalence
of the most common oral diseases in dogs in a Czech urban region. A total number of 408 dogs, presented at
a private Czech urban veterinary hospital for different reasons, were analyzed. Site specificity and severity of
dental diseases were assessed using modified indexing systems. Dental alterations could be found in 348 out of
408 dogs (85.3%). The most frequent diseases were (i) periodontitis (60.0% of 408 dogs), (ii) calculus (61.3%), (iii)
missing teeth (33.8%), and (iv) abnormal attrition (5.9%). Furthermore, single cases of caries, tumors and enamel
hypoplasia could be observed. Periodontitis occurred preferentially in the upper jaw of small dogs and increased
with age. The labial/buccal side of teeth was affected more severely than the lingual/palatinal side. Differences
between left and right side could not be observed. Malocclusion and insufficient oral hygiene care seem to predis-
pose to periodontitis. As periodontitis, dental calculus occurred preferentially in small dogs and increased with age.
The prevalence of calculus formation did not differ between left and right side. However, the upper jaw showed
a higher degree of affection than the mandible. On the labial/buccal side of the teeth, a thicker calculus layer could
be observed than lingually/palatinally. Interestingly, the degree of calculus formation and of periodontitis did not
correlate in all cases, supporting the hypothesis that supragingival calculus per se is not an irritant. The pattern of
tooth loss was the same between left and right side and between upper and lower jaw. Most commonly, the first
premolars were missing followed by incisors and other premolars and molars. Tooth loss for other reasons than
periodontitis and single cases of tooth agenesis has not been detected in our study. (Abnormal) tooth wear was
detected only in older dogs and affected mostly canines and premolars of large breeds. Age estimation based on
dental attrition should be carried out with care, because tooth wear depends on keeping conditions and feeding
of the dog. Our study confirmed the high prevalence of oral diseases in dogs. Veterinarians could improve the
effectiveness of treatment concentrating their diagnostic efforts on age groups and types of teeth at highest risk,
as assessed in this and other reports.

Keywords: periodontitis; periodontal disease; calculus; missing teeth; tooth loss; attrition; tooth wear; diagnosis

Oral disorders are of major clinical importance in al., 1991; Hoffmann and Gaengler, 1996; Harvey,
the dog. From a survey made in the United States re- 1998; Lund et al., 1999). Other important altera-
sulted that only 7% of the dog population can be con- tions are missing teeth, (abnormal) attrition, caries
sidered healthy (Lund et al., 1999). Epidemiological and tumors (Hale, 1998; Lund et al., 1999).
studies have shown that periodontal disease and Periodontal disease is the predominant disorder
dental calculus are the most common oral diseases of the oral cavity not only in dogs, but also in
in the dog (Page and Schroeder, 1981; DeMeijer et other animals (Page and Schroeder, 1982; Genco

496
Vet. Med. Czech, 50, 2005 (11): 496505 Original Paper

et al., 1998). They are mostly considered diet- Oral tumors account for six percent of all canine
related disorders (Krasse and Brill, 1960; Page tumors. The most frequent oral tumor is the squa-
and Schroeder, 1982; Genco et al., 1998; Gorrel, mous cell carcinoma (20% of oral tumors), followed
1998; Harvey, 1998; Lund et al., 1999). A soft diet by fibrosarcoma (10%), and other oral neoplasms
causes accumulation of bacterially colonized den- (Ramos-Vara et al., 2000)
tal plaque. Periodontal inflammation is a process Oral disorders in the dog represent for veterinar-
affecting the tissues surrounding the tooth. It is ians both a medical challenge and an important
induced either experimentally or occurs sponta- field of interest from the economical point of view.
neously, and is correlated to the occurrence of Therefore, in dogs have been realized numerous
gingival inflammation. The lack of oral hygiene studies on periodontal disease with large param-
causes plaque deposition and calculus formation, eters (Heijl and Lindhe, 1980; Syed et al., 1980;
which harbors the bacteria and eventually induces Newes et al., 1997; Hennet, 1999). However, most
gingival inflammation (Lindhe et al., 1975; Page of them deal with beagle dogs bred in controlled
and Schroeder, 1982). It has been suggested for environment (Rosenberg et al., 1966; Saxe et al.,
a long time that these disorders are detrimental 1967; Lindhe et al., 1975), whereas information on
only to the oral cavity. However, recently showed oral disorders in pets is far from complete. Site
some studies a close association of these disorders prevalence and severity of affections is assessed
with the general health of the animal. The per- only rarely. Available extensive epidemiological
sistent infection of the oral cavity does not only studies concerning dental disorders in humans
discomfort the affected animal, but may also cause could serve as a model for such research in animals
diseases of distant organs (DeBowes et al., 1996). (Genco et al., 1998).
Overt bacterial infections are seen only rarely, but The purpose of this retrospective study was to
the inflammatory response, which they elicit in document the prevalence of the most common oral
the gingival tissue, is ultimately responsible for diseases in dogs that were presented at a Czech
a progressive loss of collagen attachment of the urban veterinary hospital and to assess which
tooth to the underlying alveolar bone. The conse- teeth are preferentially affected. The results of this
quence is the loosening or even loss of the tooth study should alert practitioners to the main oral
(Loesche and Grossman, 2001). While feeding problems of dogs and help to communicate with
soft diets has recently become very popular with the clients/pet owners regarding these important
dog owners, proper oral hygiene care (e.g., tooth disorders.
brushing), which is proven to prevent effectively
periodontal and other oral diseases, is rarely pro-
vided (Hamp and Loe, 1973; Lindhe et al., 1973; MATERIAL AND METHODS
Hennet, 2002).
A decrease of tooth number in dogs can be caused Animals
by agenesis (mostly in small, brachycephalic breeds)
or by tooth loss in consequence of periodontal dis- This study was realized during the period of
ease or mechanical affection. Mostly are lost the 20032004. A total number of 408 dogs, which had
lower third molar, upper and lower first premolar been presented at a private Czech urban veterinary
and the incisors, usually due to periodontal disease hospital for different reasons, was analyzed for al-
(Harvey et al., 1994). The lower first premolars are terations of the oral cavity. The dogs were classified
often missing in young dogs, usually due to agen- into groups according to their age (as reported by
esis (Harvey et al., 1994; Hoffmann and Gaengler, the owners): 14 years of age, 58 years of age,
1996). 911 years of age, 1213 years of age; and accord-
Abnormal attrition is mostly observed in work- ing to their size: small breeds of less than 10 kg,
ing dogs, in dogs fed a hard diet, in dogs that love medium sized breeds 1030 kg, and large breeds of
to play with stones, and in so called wire-biters more than 30 kg body mass (Table 1). The standard
(Van Foreest and Roeters, 1998) tooth formula of the permanent dentition of the
Dental caries is a rare disease compared to other dog, which was used for determination of miss-
dental disorders in the dog. The teeth most com- ing teeth and sites of other pathological changes of
monly involved are the last premolar and the first the dentition, is I3/3, C1/1, P4/4, M2/3 (Page and
molar teeth (Hale, 1998). Schroeder, 1982).

497
Original Paper Vet. Med. Czech, 50, 2005 (11): 496505

Table 1. Age and size distribution of the examined dogs (number of the dogs)

Age groups Small breeds Medium breeds Large breeds


14 years 67 66 14
58 years 49 53 21
911 years 43 42 15
1213 years 22 9 7
Total number 181 170 57

Clinical examination and classification of In human dentistry, alterations of the periodon-


oral disorders tium are measured using the well accepted Silness
and Loe plaque index (Loe and Silness, 1963), which
Each dog was examined clinically. Number and is based on evaluation of plaque accumulation and
localization of teeth, degree and localization of gingival inflammation. This indexing system was
periodontal disease, dental calculus, dental wear used in this study with slight modifications as fol-
(attrition), dental caries and any other alterations lows, (0) Healthy gingiva without signs of gingivi-
of the oral cavity were recorded. tis, probing depth 0.01.0 mm; (1) Gingivitis with
Periodontal disease, formation of dental calcu- slight swelling and mucosa turning reddish, probing
lus and crown abrasion were scored according to depth 0.01.0 mm; (2) Early periodontal disease
a modified indexing system commonly used in the with swelling and mucosa turning reddish, probing
man. depth less than 2.5 mm; (3) Moderate periodontal

Figure 1. Stages of periodontal disease according to the Silness and Loe plaque index. (A) Stage 0, Healthy gingiva.
Gingiva clinically not inflamed, firm, pale pink in color (unless pigmented), minimal dental deposits (plaque and
calculus). No bleeding on gentle probing, probing depth 0.01.0 mm. (B) Stage 1, Gingivitis. Slight swelling of the
gingiva, hyperemia, color of turning reddish. Slight bleeding on probing, probing depth 0.01.0 mm. (C) Stage 2,
Early periodontitis. Gingiva swollen and red due to severe hyperemia. Teeth usually with dental deposits (redundant
plaque and/or calculus). Bleeding on probing, probing depth 1.02.5 mm. (D) Stage 3, Moderate periodontitis.
Inflamed gingiva, teeth with dental deposits. Bleeding on probing, probing depth up to 5.0 mm. The gingival mar-
gins begin to recede. (E) Stage 4, Severe periodontitis. Signs of clearly inflamed gingiva. Gingival recession results
in visible root surfaces and furcation involvement. Probing depth either more than 5.0 mm or very low due to a
receded gingiva

498
Vet. Med. Czech, 50, 2005 (11): 496505 Original Paper

disease with swelling and red mucosa, often with Tooth crown abrasion was classified as follows,
hemorrhages, probing depth of less than 5.0 mm; (0) No abrasion of the dental crown; (1) Abrasion
(4) Severe periodontal disease with red and swollen of less than one third of the crown; (2) Abrasion of
mucosa, alveolar bone loss, probing depth more more than one third of the crown.
than 5.0 mm (Figure 1). The degree of gingival in- In addition, all dogs, if possible, were checked for
flammation was examined separately for each tooth history of dental treatment and its details.
class region (e.g. incisor, premolar, molar region)
and for labial/buccal and lingual/palatinal side.
Formation of dental calculus was examined and RESULTS
scored by a calculus indexing system (Greene and
Vermillion, 1964) as follows, (0) No dental calculus; A total of 348 out of 408 dogs (85.3%) presented
(1) Supragingival calculus covering less than one to the small animal clinic showed dento-gingival
third of crown surface; (2) Supragingival calculus alterations. In some but not all cases, these altera-
covering more than one third but less than two tions were the reason why the owners did consult
thirds of the dental crown; (3) Supragingival cal- a veterinarian.
culus covering more than two thirds of the dental The following dental and gingival alterations
crown. Dental calculus was examined separately could be observed: (i) periodontal disease (60.0%
on both labial/buccal and lingual/palatinal surfaces of 408 dogs), (ii) calculus (61.3% of 408 dogs), (iii)
of the teeth. missing teeth (33.8% of 408 dogs), and (iv) abnor-

Table 2. Prevalence of dental disorders in pet dogs presented at a Czech urban veterinary hospital for different
reasons in dependence on age and body size

Prevalence of dental disorders (%)


Age groups
Small breeds Middle breeds Large breeds Total
Periodontal disease
14 years 53.7 31.8 21.4 40.8
58 years 68.1 47.2 42.8 53.6
911 years 86.0 88.1 66.6 85.0
1213 years 90.1 88.8 85.7 89.4
Dental calculus
14 years 53.7 48.5 28.6 48.9
58 years 57.2 58.5 42.9 55.2
911 years 76.7 85.7 60.0 78.0
1213 years 81.8 88.8 85.7 84.2
Missing teeth
14 years 22.4 19.7 7.1 19.7
58 years 28.6 41.5 0.0 29.3
911 years 51.2 59.5 40.0 53.0
1213 years 54.5 55.5 42.8 52.6
Dental attrition
14 years 0.0 0.0 0.0 0.0
58 years 0.0 0.0 28.5 4.9
911 years 4.6 19.0 25.0 14.0
1213 years 0.0 22.2 28.5 10.5

499
Original Paper Vet. Med. Czech, 50, 2005 (11): 496505

 Figure 2. Prevalence and localization


Upper jaw *ODJTPSSFHJPO
of periodontal disease in dogs (age
$BOJOFSFHJPO group 14 years) assessed by a perio-

1SFNPMBSSFHJPO dontal indexing system
 .PMBSSFHJPO
Number of dogs (out of 147)




    
Periodontal index (degree)
0 1 2 3 4
0

20

40

60

80 Lower jaw

mal attrition (5.9% of 408 dogs). The prevalence hypoplasia. These cases were so rare that they were
of these diseases depending on age and size of the not further analyzed.
dogs is shown in Table 2. Furthermore, there were Alterations of the periodontium represented the
single cases of dental caries, tumors and enamel most common oral disease in the dogs under study

 Upper jaw
* ODJ TPS  S FHJ PO
$ BOJ OF S FHJ PO
 1 S FN PM BS  S FHJ PO
 . PM BS  S FHJ PO


Number of dogs (out of 123)


    
Periodontal index (degree)
0 1 2 3 4
0

20

40
Figure 3. Prevalence and localization of
Lower jaw periodontal disease in dogs (age group
58 years) assessed by a periodontal
60 indexing system

500
Vet. Med. Czech, 50, 2005 (11): 496505 Original Paper

Upper jaw *ODJTPSSFHJPO Figure 4. Prevalence and localization


40 - of periodontal disease in dogs (age
$BOJOFSFHJPO
1SFNPMBSSFHJPO
group 911 years) assessed by a per-
30 -
iodontal indexing system
.PMBSSFHJPO
20 -
Number of dogs (out of 100)

10 -

0-

    
Periodontal index (degree)
0 1 2 3 4
0

10

20

30

40
Lower jaw

50

where 245 out of 348 dogs with dento-gingival disor- creased with the age of the animal (Table 2). The
ders were found to be positive. Dierences between prevalence of calculus formation did not differ
left and right jaw quadrant could not be observed. between left and right side, however, it did differ
The frequency of periodontal alterations as well between upper and lower jaws with a higher degree
as the degree of inammation increased with age. of affection of the upper jaw. Generally, on the la-
Earliest signs occurred rst in small breed dogs. bial/buccal side of the teeth, thicker calculus layers
Figure 1 shows typical features of gingival inam- could be observed than lingually/palatinally.
mation scored as degree (0), (1), (2), (3) and (4) The distribution pattern of dental calculus index
in the examined dogs. The single degrees of peri- was about the same between the left and right side
odontal disease were represented by increasingly and between upper and lower jaw. However, the
swollen and reddish gingiva and deep gingival sulci, dental calculus index was lower in large dogs com-
sometimes with soft deposits. Radiographs, which pared to small dogs and increased with age.
were made in some severe cases of periodontal Tooth loss increased with age (Table 2) and with
disease, revealed in every case a certain degree of increasing degree of gingival inflammation. The
alveolar bone loss. pattern of tooth loss was about the same between
Assessment of the Silness and Loe index of peri- left and right side and between upper and lower
odontal disease revealed that the labial/buccal jaw. The teeth most commonly missing were the
surface of the tooth was more affected than the first premolars followed by incisor teeth and then
lingual/palatinal surface. Periodontal alterations by other premolars and molars. Premolars followed
and gingival inflammation started mostly in the by incisors were most often missing in small sized
premolar region of both upper and lower jaw and breeds. Medium sized breeds often lost premolar
spread with increasing age first to the molars and and molar teeth, in contrast to large sized breeds,
later to other regions of the jaws (Figures 25). where only premolar teeth were frequently miss-
Periodontal disease was more frequent and more ing. The sites of missing teeth correlated with the
severe in the upper jaw in comparison with the sites of periodontal disease. There were only single
mandible (Figures 25). cases of tooth agenesis in young dogs.
Dental calculus in young age was observed mostly Dental attrition was observed only in older dogs.
in small dogs. The degree of dental calculus in- Abrasion increased with age, in single cases reach-

501
Original Paper Vet. Med. Czech, 50, 2005 (11): 496505

 *ODJTPSSFHJPO Upper jaw


Upper jaw Figure 5. Prevalence and localization of
$BOJOFSFHJPO periodontal disease in dogs (age group
1SFNPMBSSFHJPO 1213 years) assessed by a periodontal
indexing system
 .PMBSSFHJPO
Number of dogs (out of 38)


    
Periodontal index (degree)
0 1 2 3 4
0

10

Lower jaw
20

ing degree 2 in dogs older than eight years of age. Interestingly, recent studies (DeMeijer et al.,
Large breeds were generally more affected than 1991; Hoffmann and Gaengler, 1996; Harvey,
small and middle breeds (Table 2). Tooth wear did 1998; Lund et al., 1999) reveal in general a higher
neither differ between left and right side nor be- prevalence of oral disorders in dogs compared to
tween upper and lower jaw. Abrasion started in older studies, which concerned, however, mostly
canines and premolars. These teeth were also most beagle colonies (e.g., Rosenberg et al., 1966; Saxe
severely affected. et al., 1967). This can be explained either as a re-
The percentage of dogs that had received home sult of increasing prevalence of these disorders or
oral hygiene care was very low. It mostly consisted as a virtual increase, because veterinary clinicians
of daily tooth brushing using a tooth paste designed are more often requested for dental treatments in
for animals and regular scaling of dental calculus dogs. It might be also a misinterpretation because
by veterinary surgeons. of different approaches to epidemiological studies
(Preshaw et al., 2004).
Periodontal disease seems to be one of the most
DISCUSSION common oral disorders in small animals (Gorrel,
1998). We observed an increasing prevalence and
This study aimed to assess the prevalence of severity of periodontal disease with increasing age
oral diseases of pet dogs in a Czech urban region. of the dogs. These ndings are in agreement with
Periodontal disease, dental calculus and tooth loss previous experimental studies on beagle colonies
were the most frequent alterations found in this (Rosenberg et al., 1966; Saxe et al., 1967) as well as
study. Similar results were also reported by other with retrospective studies in pet dogs (Harvey et al.,
authors (Lindhe et al., 1973; Page and Schroeder, 1994; Homann and Gaengler, 1996; Harvey, 1998;
1982; DeMeijer et al., 1991; Harvey et al., 1994; Lund et al., 1999). Interestingly, these studies revealed
Hoffmann and Gaengler, 1996; Genco et al., 1998; that the disease develops spontaneously in dogs fed
Gorrel, 1998; Harvey, 1998; Lund et al., 1999). with both homemade and commercial-type diet.
Additionally, our study revealed few cases of other We observed a higher frequency and earlier onset
oral disorders such as oral tumors, enamel hypo- of periodontal disease in small breed dogs compared
plasia, tooth attrition and dental caries, which have to large breeds. This state could be explained by ge-
also been described to be found in dog populations netic predisposition, which render the gingiva more
(DeMeijer et al., 1991; Lund et al., 1999). susceptible to periodontal disease. Also malocclu-

502
Vet. Med. Czech, 50, 2005 (11): 496505 Original Paper

sions, which are very common in small breeds, ex- status of the periodontal tissue. These authors
pose the teeth to deposition of subgingival plaque observed that about 95% of pet dogs fed either a
resulting in periodontal disease. Some reports show homemade or commercial type diet show heavy
that all dogs older than 5 years of age suer from calculus deposition at the age of 26 months and that
some degree of periodontal disease (e.g., Hamp and the gingival inflammation becomes more severe
Loe, 1973; Homann and Gaengler, 1996). with increasing age. However, calculus itself does
The most often inflamed site of gingiva in dogs not seem to be an irritant. In fact, it has been shown
is apparently the premolar region followed by the that under certain conditions a normal attachment
molar and then the incisor region. The labial/buccal may be seen between the junctional epithelium of
gingiva is more affected than the lingual/palatinal the gingiva and calculus (Fitzgerald and McDaniel,
gingiva. In contrast to the dog, the molar region is 1960). Autoclaved calculus can be encapsulated in
most predilected for periodontal disease in the hu- connective tissue without causing marked inflam-
man (Loesche and Grossman, 2001; Newman and mation (Allen and Kerr, 1965). Our study supports
Carranza, 2002), probably because it is difficult to this information, since thick calculus deposits have
remove plaque by simple brushing in this region been found in many examined dogs with only a
(Newman and Carranza, 2002). Dogs usually do light degree of gingival inflammation. Apparently,
not receive oral hygienic treatment. supragingival calculus per se is not directly involved
According to our study, the gingiva seems to be in the etiology or even pathogenesis of periodontal
more often inflamed in the upper jaw than in the disease and is mainly of cosmetic significance if
mandible. These results are, however, in contradic- plaque is not too large (Lang et al., 1997). However,
tion with most other reports (Hamp and Loe, 1973; plaque can be indirectly responsible for gingival
Harvey et al., 1994; Hoffmann and Gaengler, 1996) inflammation as a result of the immune response
indicating the same prevalence in both areas. of the host (Bascones et al., 2004).
Development of periodontal disease varies at dif- Loosening of teeth and following tooth loss is
ferent sites. The same dentition may show both often elicited by inflammatory response in the
normal sites and sites with gingivitis and perio- gingival tissue, which leads to a progressive loss
dontal disease. For planning and evaluation of the of collagen attachment of the tooth to the un-
effect of treatment, diagnosis should be therefore derlying alveolar bone (Loesche and Grossmann,
site specific (Harris, 2003). In our study, there were 2001). Our study revealed a relatively large number
no differences between right and left side, but be- of missing teeth in the examined dogs. The sites
tween the individual tooth regions. The sites of of missing teeth agreed with other reports (Page
most severe affection differed in dependence on and Schroeder, 1981): the first premolars; then the
the animal group. other premolars and incisors, and finally molars en-
Simple periodontal disease indicators (scores) al- suing. Interestingly, the sites of marked periodontal
lowing to choose appropriate treatment methods disease were similar to those of missing teeth. The
and to predict clinical outcome, which are suitable number of missing teeth increased with the pro-
for the screening of large animal populations, are gression of periodontal inflammation and with age,
still lacking (Harvey et al., 1994). Whether index- suggesting a causal relationship between these two
es adapted from human medicine (e.g., Loe and alterations (Page and Schroeder, 1982). Tooth loss
Silness, 1963) will be helpful remains to be tested. for other reasons than periodontal disease or tooth
Biopsy of apparently diseased tissue followed by agenesis has not been detected in our study. Some
histological examination might be useful as an ad- studies present also other causes of missing teeth,
ditional diagnostic tool (Johnson et al., 1988). such as traumatic tooth loss (Bittegeko et al., 1995;
Accumulation of dental calculus increases, simi- Dole and Spurgeon, 1998).
larly as periodontal disease, with the age of the Attrition of teeth becomes apparent in older dogs
animal. Our study revealed that dental calculus ap- (older than eight years of age). The age of dogs can
peared in some small breed dogs as early as at one be estimated based on the degree of dental attri-
year of age. These dogs had persistent deciduous tion. This method is, however, highly speculative,
teeth, which caused malocclusion and thus cre- because tooth wear depends on feed and keeping
ated an optimal surface for plaque accumulation. conditions (Berglundh et al., 1991).
According to Rosenberg et al. (1966), the pattern In agreement with a previous report (Hoffmann
of calculus formation matches the inflammation and Gaengler, 1996), our study revealed no den-

503
Original Paper Vet. Med. Czech, 50, 2005 (11): 496505

tal caries in the examined dogs. The scarcity of ing canine distemper infection. Journal of the Ameri-
dental caries contrasts with the high prevalence can Animal Hospital Association, 31, 4245.
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reason is unexplained at present. It is speculated S., Richardson D.C. (1996): Association of periodontal
that the oral condition of the dog including the disease and histologic lesions in multiple organs from
oral bacterial flora may be suitable rather for the 45 dogs. Journal of Veterinary Dentistry, 13, 5760.
development of periodontal disease than for dental DeMeijer L.M., Van Foreest A.W., Truin G.J., Plasschaert
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no evidence to support this assumption so far. merary teeth in a dolichocephalic canine breed, the
Our study as well as many others showed the high greyhound. American Journal of Veterinary Research,
prevalence of oral diseases in dogs and confirmed 59, 1617.
that periodontal disease is the most common oral Fitzgerald R.J., McDaniel E.G. (1960): Dental calculus in
condition in dogs. It is well known from human the germ-free rat. Archives of Oral Biology, 2, 239240.
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Lindhe J., Hamp S.E., Loe H. (1973): Experimental per- son G.C., Pace L.W., Fard A., Kottler S.J. (2000): Ret-
iodontitis in the beagle dog. International Dental Jour- rospective study of 338 canine oral melanomas with
nal, 23, 432437. clinical, histologic, and immunohistochemical review
Lindhe J., Hamp S.E., Loe H. (1975): Plaque induced of 129 cases. Veterinary Pathology, 37, 597608.
periodontal disease in beagle dogs. A 4-year clinical, Rosenberg H.M., Rehfeld C.E., Emmering T.E. (1966): A
roentgenographical and histometrical study. Journal method for the epidemiologic assessment of periodon-
of Periodontal Research, 10, 243255. tal health-disease state in a beagle hound colony. The
Loe H., Silness J. (1963): Periodontal disease in preg- Journal of Periodontology, 37, 208213.
nancy. Prevalence and severity. Acta Odontologica Saxe S.R., Greene J.C., Bohannan H.M., Vermillion J.R.
Scandinavica, 21, 533551. (1967): Oral debris, calculus, and periodontal disease
Loesche W.J., Grossman N.S. (2001): Periodontal disease in the beagle dog. Periodontics, 5, 217225.
as a specic, albeit chronic, infection: diagnosis and treat- Syed S.A., Svanberg M., Svanberg G. (1980): The pre-
ment. Clinical Microbiology Reviews, 14, 727752. dominant cultivable dental plaque flora of beagle dogs
Lund E.M., Armstrong P.J., Kirk C.A., Kolar L.M., Klaus- with gingivitis. Journal of Periodontal Research, 15,
ner J.S. (1999): Health status and population charac- 123136.
teristics of dogs and cats examined at private veterinary Van Foreest A., Roeters J. (1998): Evaluation of the clin-
practices in the United States. Journal of the American ical performance and effectiveness of adhesively-
Veterinary Medical Association 214, 13361341. bonded metal crowns on damaged canine teeth of
Newes M.A., Harwig P., Kinyon J.M., Riedesel D.H. working dogs over a two- to 52-month period. Journal
(1997): Bacterial isolates from plaque and from blood of Veterinary Dentistry, 15, 1320.
during and after routine dental procedures in dogs.
Veterinary Surgery, 26, 2632. Received: 050714
Accepted after corrections: 051118

Corresponding Author

Michal Kyllar, Institute of Anatomy, Histology and Embryology, Faculty of Veterinary Medicine, University
of Veterinary and Pharmaceutical Sciences Brno, Palackeho 13, CZ-612 42 Brno, Czech Republic
Tel. +420 541 562 204, fax +420 541 562 217, e-mail: kyllarm@yahoo.com

505
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Journal of Feline Medicine and Surgery (2014) 16, 900913

CLINICAL REVIEW

APPLIED FELINE ORAL ANATOMY AND


TOOTH EXTRACTION TECHNIQUES
An illustrated guide
Alexander M Reiter and Maria M Soltero-Rivera

Practical relevance: Tooth extraction Feline oral anatomy


is one of the most commonly performed
surgical procedures in small animal Eruption and types of teeth
practice. The kittens 26 deciduous teeth erupt at between 2 and 6 weeks of age.
Clinical challenges: The clinician must The cats 30 permanent teeth erupt at between 3 and 6 months of age.
be familiar with normal oral anatomy, Cats have incisors for cutting, prehending and grooming, canines
utilize nomenclature accepted in dentistry and for penetrating, grasping and defense, and cheek teeth (premolars
oral surgery, use the modified Triadan system for and molars) for holding, carrying, breaking and tearing food. The
numbering teeth, identify normal structures on a maxillary fourth premolar and mandibular first molar are the carnas-
dental radiograph, understand the tissues that hold sial teeth.13
the teeth in the jaws, know the biomechanical
principles of tooth extraction, be able to choose the Tooth structure
most appropriate instrument for removal of a tooth, Enamel covers the crown and cementum covers the root. These hard
extract teeth using closed and open techniques, tissue layers meet at the cemento-enamel junction near the cervical
and create tension-free flaps for closure of
extraction sites.
Audience: This review is intended to familiarize
both the general and referral practitioner with feline Figure 1
oral anatomy and tooth extraction techniques. Radiographs of
the mandibular
Patient group: Tooth extraction is predominantly incisors and
performed in cats with tooth resorption, chronic canines, and the
right mandibular
gingivostomatitis and periodontal disease. cheek teeth in
Equipment: The basic contents of a feline tooth a cat less than
1 year of age (A
extraction kit are explained. and B) and in a
Evidence base: The guidance contained within cat over 3 years
of age (C and D).
this review is based on a combination of the E = enamel;
published literature, the authors personal PC = pulp
chamber;
experience and the experience of colleagues. D = dentin;
RC = root canal;
A = apex;
MS = mandibular
Permanent teeth of young symphysis;
AM = alveolar
cats have a much wider pulp margin;
LD = lamina dura;
PLS = periodontal
cavity and thinner dentinal ligament space;
F = furcation;
walls compared with MC = mandibular
canal
permanent teeth of old cats.

Alexander M Reiter
Dipl Tzt Dr med vet DAVDC DEVDC*
Maria M Soltero-Rivera
DVM DAVDC
Department of Clinical Sciences, School of
Veterinary Medicine, University of Pennsylvania,
3900 Delancey Street, Philadelphia, PA, USA

*Corresponding author: reiter@vet.upenn.edu

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To o t h f o r m u l a s a n d d i r e c t i o n a l t e r m s
The anatomical names of teeth are (right or left), (maxillary or < Left mandibular quadrant 300 (700 when referring to
mandibular), (first, second, third or fourth), (incisor, canine, deciduous teeth)
premolar or molar), as applicable, either written out in full or < Right mandibular quadrant 400 (800 when referring to
abbreviated. deciduous teeth)
Beginning with the first incisor (01), teeth are numbered from
Modified Triadan system mesial to distal along the dental arch. Evolutionarily missing
The modified Triadan system numbers each jaw quadrant as teeth result in gaps in the numbering sequence (Figure 2).
follows: The maxillary first (05) premolars and mandibular first (05) and
< Right maxillary quadrant 100 (500 when referring to second (06) premolars are absent in the cat. The maxillary and
deciduous teeth) mandibular canines (04), maxillary fourth premolars (08) and
< Left maxillary quadrant 200 (600 when referring to mandibular first molars (09) are large reference teeth that allow
deciduous teeth) counting forward or backward when numbering all other teeth.13

Figure 2 Modified
Triadan tooth numbering
system for the maxillary
(A) and mandibular (B)
permanent teeth in the
cat

The directional ter-


minology that is used
is illustrated in Figure
3 and tabulated below.

Figure 3 Directional
terminology for maxillary
(A) and mandibular (B) teeth
in the cat. M = mesial;
La = labial; B = buccal;
D = distal; P = palatal;
Li = lingual

Rostral Towards the tip of the nose Lingual Facing the tongue
Caudal Towards the tail Palatal Facing the hard palate
Ventral Towards the lower jaw Occlusal Facing an opposing dental arch
Dorsal Towards the top of the head or the muzzle Coronal Towards the tip of the crown
Mesial Towards the midline along the dental arch Apical Towards the apex of a root
Distal Away from the midline along the dental arch Subgingival Apical to the gingival margin
Labial Facing the lip Supragingival Coronal to the gingival margin
Buccal Facing the cheek

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portion of the tooth. dentin makes up the bulk Bones, joints and muscles
of the mature tooth. The pulp cavity, which Mesaticephalic cats have a head of medium
contains the pulp, is divided into the pulp proportions. Persians are brachycephalic with
chamber in the crown and the root canal(s) in a short, wide head. Siamese are dolicho-
the root(s). The feline pulp connects with peri- cephalic with a long, narrow head.
apical tissues through several foramina in the The upper jaw and face consist of the paired
root apex (apical delta). Non-apical ramifica- incisive bones, maxillae, palatine, nasal, zygo-
tions exist in the furcation and other areas of matic and temporal bones, and the unpaired
the root. odontoblasts at the pulps periphery vomer bone. The incisive bones carry the max-
produce dentin throughout life in a vital illary incisors, and the maxillae carry the
tooth. Therefore, permanent teeth of young maxillary canines, premolars and molars. The
cats have a much wider pulp cavity and thin- infraorbital canal contains the infraorbital
ner dentinal walls (Figure 1) compared with artery, vein and nerve (sensory), and lies dor-
permanent teeth of old cats.13 Figure 4 Different types of sal to the maxillary fourth premolar and first
incisors and canines are single-rooted teeth. oral mucosa in the upper (A) molar; the neurovascular bundle exits the
and lower (B) jaws of a cat.
Permanent maxillary second premolars and Note the unpaired incisive canal at the infraorbital foramen about 1 cm
first molars often have two roots fused to papilla immediately caudal dorsal to the maxillary third premolar.1,3
to the maxillary first incisor
each other (allowing them to be extracted teeth (arrowhead) and The lower jaw consists of the paired
without tooth sectioning). Permanent the lingual molar gland mandibulae, carrying all the mandibular
contained within a
mandibular third and fourth premolars and membranous pad teeth. The mandibular canal contains the infe-
first molars have two roots, while the maxil- caudolingual to the rior alveolar artery, vein and nerve (sensory),
mandibular first molar tooth
lary fourth premolars have three roots. The (arrow). The dotted line
which exit at the caudal, middle and rostral
two-rooted permanent maxillary third pre- depicts the approximate mental foramina. The mandibular symphysis,
molars occasionally have a third root.4 The course of the mucogingival
junction
furcation is where two or more roots meet at
the crown.13

Periodontium and oral mucosa


The periodontium is made up of gingiva,
periodontal ligament, cementum and alveolar
bone. The inelastic gingiva attaches to the
cervical portion of the tooth and most coronal
portion of the alveolar bone. its most coronal
edge is called the gingival margin. The space
between the tooth and the free gingiva is the
gingival sulcus, which should not be deeper
than 0.5 mm in cats.3 The periodontal liga-
ment attaches the root to alveolar bone.
Cementum is produced by cementoblasts, and
its width increases with age. Alveolar bone
surrounds the alveolar socket. The most coro-
nal edge of the alveolar bone is the alveolar
margin. The periodontal ligament space
appears radiographically as a dark line sur-
rounding the root. immediately adjacent to it
is the radiopaque lamina dura, an extension of
cortical bone into the alveolus.2,3
Alveolar mucosa is elastic, faces the alveolar
bone and is separated from the gingiva by the
mucogingival junction. Labial and buccal
mucosae cover the inside of the lip and cheek
(Figure 4). Together with the tongue, the loose
sublingual mucosa covers the floor of the
mouth. The mucosa at the dorsal and ventral
tongue surfaces contains many different
papillae. The inelastic mucosa of the hard
palate is firmly attached to the palatine
processes of the maxillae and the palatine
bones. Finally, the mucosa of the muscular
soft palate contains small salivary glands. The
oral mucosa is separated from the skin by the
mucocutaneous junction.3

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a fibrocartilaginous synchondrosis, connects


the two mandibles rostrally. The condylar Indications for tooth extraction
process of the mandible and the mandibular The most common indications for tooth extraction in cats include tooth
fossa and retroarticular process of the tempo- resorption and stomatitis, followed by retained roots and teeth with
ral bone form the temporomandibular joint. periodontal or endodontic/periapical disease.6
The masseter, temporal and pterygoid
(medial and lateral) muscles close the mouth.
The digastricus muscles open the mouth.1,3
Equipment, instruments and
Lips and cheeks materials for tooth extraction
The upper and lower lips meet at the commis-
sure. The dorsal and ventral buccal branches Keeping a cats mouth open wide for a pro-
of the facial nerve (for motor innervation) run longed period of time can reduce maxillary
over the masseter muscle in a caudorostral artery blood flow, which may result in
direction into the cheek. Traversing in temporary or permanent blindness post-
between the two nerves is the parotid duct, anesthesia.7,8 Rather than using spring-loaded
which opens into the mouth at the parotid mouth gags, 30 mm or 20 mm plastic gags that
papilla in the buccal mucosa near the maxil- are custom-made from a needle cap can be
lary fourth premolar.13 placed between maxillary and mandibular
canines to enable adequate mouth opening
Palate for performance of extraction procedures
The roof of the mouth is divided into non-elas- (Figure 5).
tic hard palate and elastic soft palate. The hard Air-powered systems are equipped with
palate mucosa has several transverse ridges irrigating mechanisms to cool the burs used
(palatine rugae). The unpaired incisive papilla in high- and low-speed dental handpieces.9
is immediately caudal to the maxillary first inci- High-speed handpieces are used for section-
sor teeth. The paired major palatine arteries ing multi-rooted teeth into single-rooted
course from the major palatine foramina at the crownroot segments and for removing and
level of the maxillary fourth premolars rostrally shaping alveolar bone; low-speed handpieces
to the palatine fissures. Palatoglossal folds are used for cutting bone only. An assortment
emerge when the tongue is withdrawn from the of round (to remove alveolar bone), cross-cut
mouth, running from the body of the tongue to
the rostrolateral aspect of the soft palate.1,3

Tongue
The cat uses its muscular tongue to lap fluids,
form food boluses and groom the fur. The ros-
tral two-thirds are the body of the tongue; the
caudal one-third is the root of the tongue. The
rough dorsal tongue surface has firm papillae
pointing caudally. The lingual frenulum con-
nects the lingual body to the floor of the mouth.
The mandibular and sublingual ducts open at
the sublingual caruncles at the rostroventral
base of the frenulum. The paired lingual arteries
supply the tongue. The lingual and facial nerve
provide sensory function, while the hypoglossal
nerve is responsible for motor function.1,3

Salivary glands, lymph nodes and tonsils


Cats have four pairs of major salivary glands
(parotid, sublingual, mandibular and zygo-
matic). Scattered glandular tissue is present
submucosally in the lips, cheeks and soft
palate. Caudolingual to each mandibular first
molar tooth is a small lingual molar gland
contained within a membranous pad.2,5 There
are three lymph centers in the head (parotid,
mandibular and retropharyngeal). The pala- Figure 5 (A) Spring-loaded mouth gag, 20 mm custom-made
plastic gag, 30 mm custom-made plastic gag and 42 mm
tine tonsils are attached to the dorsal aspect of common 1 inch needle cap. (B and C) A 20 mm custom-made
the lateral pharyngeal walls, which are also plastic gag placed between maxillary and mandibular canines
enables adequate mouth opening for performance of tooth
called the fauces.13 extraction in the upper and lower jaw quadrants

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dental luxators have sharp, flat-tipped


blades for penetrating and cutting the perio-
dontal ligament between the tooth and alveo-
lar bone. dental elevators have less sharp,
more curved blades (Figure 8), fitting the cir-
cumference of the tooth to exert a rotational
force, thus tearing the periodontal ligament
fibres. These instruments are grasped with the
butt of the handle seated in the palm, and the
index finger extended along the blade to act as
a stop in case the instrument slips.9 Small root
Figure 6 Assortment of friction-grip burs for use in a high-speed dental handpiece; tip luxators, elevators and forceps are avail-
round carbide burs (left), cross-cut fissure burs (middle) and round medium-coarse diamond able for removal of root remnants (Figure 9).
burs (right). S = surgical (ie, the shank is longer than normal); L = long (ie, the working end is
longer than normal) The beaks of extraction forceps should not

Figure 8 Winged dental elevators (sizes 14, from left to


right), the curved blades of which are designed to fit the
circumference of a tooth

Figure 7 Feline tooth extraction kit. Root fragment elevators (A), winged luxating elevators (B),
extraction forceps (C), root tip forceps (D), needle holder (E), suture scissors (F), curved
Metzenbaum scissors (G), Adson thumb forceps (H), scalpel handle (I), surgical curette (J)
and periosteal elevators (K)

fissure (to section multi-rooted teeth) and


Luxators and round diamond burs (to smooth alveolar
bone) should be available (Figure 6).
elevators are Numbers 3 (with metric ruler markings) and
grasped with the 5 scalpel handles accept numbers 10, 11, 15 and
15C blades.10 Adson 1 x 2 forceps provide a
butt of the handle fine rat tooth grip, causing minimal trauma to
delicate oral tissues. it is suggested that oral
seated in the palm, flaps are grasped on their connective tissue
and the index finger side rather than at their margins so as not to
traumatize the latter prior to suturing. Sharp
extended along and narrow-tipped periosteal elevators (such
as Glickman 24G or Periosteal EX-9) are used
the blade to act as to raise oral flaps and should always
a stop in case of be part of a feline tooth extraction kit (Figure
7). The flat or concave side of the blade is used
slippage. against the bone and the convex side against
the soft tissue, reducing the risk of tearing or
puncturing the elevated soft tissue.9 Figure 9 Small root tip luxators and root tip elevators
(teasers) for removal of root remnants

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fully close but still fit the circumference of Tooth extraction techniques
feline teeth, thus reducing the risk of tooth Practical
fracture when a tooth or crownroot segment considerations Closed extraction
is grasped as far apically as possible for its < If a tooth needs Closed extraction in the cat is primarily
removal.11 to be extracted in performed for maxillary and mandibular
Surgical curettes are used for removal of the area of previous incisors, maxillary second premolars, maxil-
debris and granulation tissue from an alveolar radiation therapy, lary first molars, and mobile teeth presenting
socket after tooth extraction. Curved, blunt- the procedure with significant attachment loss. Employing a
ended Metzenbaum scissors with serrated should be closed extraction technique for other teeth
blades are used for dissecting the connective performed soon risks their fracture, which then warrants an
tissue side of oral flaps and fine cutting of after the acute side open extraction technique in order to remove
their edges prior to wound closure. Specific effects have worn root remnants.
suture scissors or a designated pair of Mayo off (eg, after 68 The gingival attachment around the tooth is
scissors should be reserved for cutting weeks) rather than incised with a number 15 scalpel blade. A den-
sutures.10 Halsey or deBakey needle holders waiting months or tal elevator with a curved blade that best fits
with serrated jaws are used to lock onto years, as the the circumference of the tooth is selected. The
curved needles by a ratchet mechanism. The potential for wound instrument is inserted into the periodontal lig-
authors prefer a size 5-0 synthetic, absorbable healing will not ament space between the tooth and alveolar
monofilament material with a swaged-on, improve but bone. Careful and steady rotation of its handle
taper-point round, non-cutting needle for become will create pressure on the tooth and causes
suturing tooth extraction sites in cats (Figure progressively the periodontal ligament to stretch and tear.3
10). Square or surgeons knots should be worse. (Note that performing a wiggling motion has
followed by four more throws to ensure knot < Obtaining the potential to crush adjacent alveolar bone.)
security.9 signed or As the periodontal ligament space is widened,
Chlorhexidine gluconate (0.12%) is used for witnessed verbal the dental elevator can be advanced apically
rinsing the mouth prior to tooth extraction. consent from the and rotational pressure is repeated. The instru-
The results of a study conducted on canine client about the ment should be inserted at other sites around
fibroblasts suggest that the least toxic solution number of teeth the tooth until it is mobile enough for retrieval
for rinsing open wounds is lactated Ringers to be removed is with an extraction forceps. The apex of the
solution.9 Autogenous bone (cancellous bone important prior to extracted tooth is inspected and palpated,
and cortical bone chips) as well as allograft- performing any ensuring no fracture has occurred. The extrac-
based (demineralized bone of the same tooth extraction. tion site is debrided with a surgical curette,
species) and ceramic-based (calcium phos- and sharp bony edges are smoothed. The
phate, calcium sulfate and bioglass) bone graft wound is rinsed and then sutured closed in a
substitutes are most commonly used in veteri- simple interrupted pattern.6,14
nary dentistry, although they are not routinely Sectioning of multi-rooted teeth provides
needed in extraction sites.12,13 Gauze swabs two or more single-rooted crownroot seg-
(size 3 x 3 inches, 7.5 x 7.5 cm) allow digital ments that are extracted as if they were single-
control of hemorrhage during tooth extraction rooted teeth. Gentle reflection of the gingiva
procedures. Lavage with refrigerated lactated with a periosteal elevator will reveal the exact
Ringers solution may also provide good location of the furcation, decreasing the risk of
hemostasis. Excessive bleeding from tooth damage to the gingiva during tooth section-
extraction sites near tubular structures such as ing. Sectioning is accomplished with a fissure
the mandibular and infraorbital canals can bur, starting from the furcation and progress-
effectively be controlled by packing the alveo- ing through the crown.3 Two-rooted teeth are
lar sockets with a small amount of bone wax (a separated into two single-rooted crownroot
sterile beeswax-based compound).9 segments. The three-rooted maxillary fourth
premolar tooth is separated into three one-
rooted crownroot segments. in addition to
vertical advancement of a dental elevator into
the periodontal ligament space, the instru-
ment can also be inserted horizontally in
between the sectioned crownroot segments
to lever them out of their alveoli.6,14

Closed extraction is primarily performed for


maxillary and mandibular incisors, maxillary second
premolars, maxillary first molars, and mobile teeth
Figure 10 Size 5-0 synthetic, absorbable monofilament
material with a swaged-on, taper-point round, non-cutting presenting with significant attachment loss.
needle

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R E V I E W / Oral anatomy and tooth extraction

Open extraction or two releasing incisions, extending from the


Feline teeth are quite delicate due to their gingival margin over the mucogingival junc-
small size and become even more brittle when tion 37 mm (depending on flap location) into
affected by resorption. An open extraction alveolar mucosa, are made and a full-thick-
technique is employed particularly when ness (mucoperiosteal) flap is raised. Smaller to
multiple teeth in one jaw quadrant require mid-sized, round carbide burs attached to a
removal. other indications for open extraction water-cooled dental handpiece are used to
include large and periodontally intact perma- remove alveolar bone at the labial and buccal
nent teeth, unerupted teeth and rather rare tooth surface by as much as one- to two-thirds
in the cat firmly seated deciduous canine of the length of each root.3 Septal bone does
teeth. Extraction of maxillary and mandibular not have to be removed, except when
canine and cheek teeth in a cat is illustrated in approaching the mesiopalatal root of the
Figures 1123. maxillary fourth premolar. Narrow slots can
The gingival attachment around the tooth is be created at mesial and distal aspects of each
incised with a number 15 scalpel blade. one root to allow for better elevator purchase.

Open extraction of left maxillary canine (204) and cheek teeth (206209) in a cat

Figure 11 A
vertical releasing
incision is made
into gingiva and
alveolar mucosa
at the mesial
aspect of the
canine tooth (A).
A triangular oral
flap is raised with
a periosteal
elevator (B and C);
note the position
of the infraorbital
neurovascular
bundle as it exits
the infraorbital
canal at the
infraorbital
foramen (arrow).
Alveolectomy is
performed with a
round bur (D)

Figure 12 Narrow
slots are created
with a round
carbide bur at
mesial and distal
aspects of each
root (A). Multi-
rooted teeth are
sectioned with a
cross-cut fissure
bur (B). The
mesiopalatal
crownroot
segment must be
separated from
the mesiobuccal
crownroot
segment of the
fourth premolar
tooth (C and D)

Continued on
pages 907910

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R E V I E W / Oral anatomy and tooth extraction

nective tissue side of the flap is debrided with


Open extraction is performed principally when a surgical curette, ensuring removal of infect-
multiple teeth in one jaw quadrant require removal, ed and inflamed granulation tissue. Utilizing
stay sutures or grasping a flap on its connec-
as well as for large and periodontally intact tive tissue side with a thumb forceps will
minimize iatrogenic trauma to the flap mar-
permanent teeth and unerupted teeth. gin. The periosteum at the base of the flap is
incised in a distomesial direction, allowing the
flap to become mobile.15 The back of a scalpel
Sectioning of multi-rooted teeth, extraction of blade can be used to strum and weaken the
crownroot segments, debridement and rinsing periosteal layer, followed by blunt dissection
of the wound are performed as described for with scissors. A small stab incision might also
the closed extraction technique. Slight deflec- be made in the periosteum through which the
tion of lingually/palatally located gingiva blade tips of closed scissors are inserted and
allows for safe smoothing of alveolar bone and opened to undermine the periosteal layer. The
avoids iatrogenic injury to soft tissues.3,6,14 wound is rinsed and the flap sutured to the
irregular or necrotic flap margins are palatal/lingual gingiva in a simple interrupt-
trimmed with Metzenbaum scissors. The con- ed pattern.3,16,17

Continued from
page 906

Figure 13 A
dental elevator
is inserted into
the periodontal
ligament space
between the
canine tooth and
alveolar bone, and
rotated to stretch
and tear the
periodontal
ligament (A and
B). Once the tooth
is mobile enough,
it is grasped as
far apically as
possible with an
extraction forceps
and removed
(C and D)

Figure 14
Fracture of the
mesial crownroot
segment of the
third premolar has
occurred (A).
Additional alveolar
bone around the
root remnant is
removed with a
round carbide bur
(B). A special root
tip elevator is
used to elevate
and retrieve the
root remnant
(C and D)

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Continued from
pages 906907

Figure 15 The
mesiopalatal
crown-root
segment of the
fourth premolar
is still in place (A).
The septal bone
separating the
already extracted
mesiobuccal
crownroot
segment from
the mesiopalatal
crownroot
segment is
reduced with a
round carbide
bur (B). The
mesiopalatal
crownroot
segment is
elevated and
removed (C and D)

Figure 16 The
first molar tooth
is extracted (A).
The gingiva on
the palatal aspect
is elevated (B).
Sharp bony edges
are smoothed with
a round medium-
coarse diamond
bur (C), and the
alveolar sockets
are debrided with
a surgical curette
(D)

Figure 17
Irregular wound
margins are
trimmed with
tissue scissors
(A). The
periosteum at
the base of the
flap is incised with
a blade (B) and
bluntly dissected
with tissue
scissors (C).
The flap is sutured
to the palatal
gingiva in a
simple interrupted
pattern (D)

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R E V I E W / Oral anatomy and tooth extraction

Continued from
pages 906908

Figure 18 Dental radiographs obtained


before (A) and after (B) tooth extraction.
The extracted teeth are lined up (C)

Figure 19 A
vertical releasing
incision is made
into gingiva and
alveolar mucosa
at the mesial
aspect of the
canine tooth (A).
A triangular oral
flap is raised with
a periosteal
elevator (B and C);
note the position
of the middle
mental
neurovascular
bundle as it exits
the mandibular
canal at the
middle mental
foramen (arrow).
Alveolectomy is
performed with a
round bur (D)

Figure 20 Narrow
slots have been
created with a
round bur at
mesial and distal
aspects of each
root (A). Multi-
rooted teeth are
sectioned with a
cross-cut fissure
bur; note that the
furcation of the
first molar is distal
to the middle of its
M-shaped crown
(B). The canine
tooth is elevated
and removed
(C and D)

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R E V I E W / Oral anatomy and tooth extraction

Continued from
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Figure 21 The
sectioned
crownroot
segments of the
first molar are
elevated and
removed (AC).
The gingiva on the
lingual aspect is
elevated (D)

Figure 22 The
gingiva on the
lingual aspect is
elevated up to the
empty alveolus
of the extracted
canine tooth to
facilitate suture
placement (A).
Sharp bony edges
are smoothed with
a round medium-
coarse diamond
bur (B). Irregular
wound margins
are trimmed with
tissue scissors
(C). The flap is
sutured to the
lingual gingiva in a
simple interrupted
pattern (D)

Figure 23 Dental radiographs obtained


before (A) and after (B) tooth extraction.
The extracted teeth are lined up (C)

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R E V I E W / Oral anatomy and tooth extraction

Extraction of root remnants


Root remnants under healthy gingiva and
embedded within normal bone (eg, no peri-
apical pathology) may be left where they are.
in cats, they often appear clinically as a small
gingival bulge in the area of a missing tooth.
Retained roots that poke through the gingi-
va, root remnants with sinus tracts, roots frac-
tured during the extraction procedure, and
roots remaining after mandibulectomies and
maxillectomies must be removed to prevent
infection and inflammation of the bone.3,18,19
The temptation to utilize a bur in a dental
handpiece to pulverize or drill out a retained
root must be resisted. Complications associated
with this amateurish technique include incom-
plete removal of dental tissue, alveolar bone
damage, injury to inferior alveolar and infra-
orbital neurovascular bundles, transportation
of root tissue into the mandibular canal, infra-
orbital canal or nasal cavity, and subcutaneous
Figure 24 Clinical photographs showing crown amputation of the left maxillary canine tooth
and sublingual emphysema and air embolus.6 (204) with intentional retention of resorbing root tissue in a cat. A mucoperiosteal flap is raised
Special root tip elevators and root tip for- (A). The crown is amputated with a cross-cut fissure bur at the level of the cervical portion of the
tooth (B). The resorbing root is reduced with a round medium-coarse diamond bur to about
ceps are available for removal of small root 12 mm below the level of the alveolar margin (C). The gingiva is sutured closed over the wound (D)
remnants. if removal in a closed fashion is not
possible, a mucoperiosteal flap and partial
alveolectomy should be performed to facili- ity, periodontitis, endodontic disease, peri-
tate complete tooth extraction.20 if the tooth apical pathology and stomatitis, teeth with
fractures during open extraction, additional Root remnants dentoalveolar ankylosis and root replacement
alveolar bone (if necessary, the entire alveolar resorption can be managed by crown amputa-
bone labial or buccal to the root remnant) is
under healthy tion with intentional retention of resorbing
removed so that the root remnant can safely gingiva and root tissue. This procedure should only be
be retrieved. An endodontic file can be thread- employed when closed or open extraction
ed into the root canal of a root remnant to help embedded cannot be accomplished on teeth with radio-
retrieve it.21 Retrieval of root remnants from graphic confirmation of dentoalveolar ankylo-
within normal
the mandibular canal, infraorbital canal or sis and root replacement resorption.3
nasal cavity after accidental repulsion into bone may be The procedure begins by incising the gin-
these spaces must be carefully planned to gival attachment around the tooth. A muco-
avoid significant hemorrhage.3 left where periosteal flap with or without releasing inci-
they are. sions is made. The crown is severed from the
Crown amputation remainder of the tooth with a round or fissure
Many teeth in cats undergo dentoalveolar bur attached to a high-speed handpiece. The
ankylosis and root replacement resorption. resorbing root is further reduced with a round
Such teeth have lost their periodontal liga- diamond bur to about 12 mm below the level
ment space and the roots are fused to alveolar of the alveolar margin (Figures 24 and 25).
bone. Therefore, in the absence of tooth mobil- This allows a blood clot to form over the
remaining root tissue into which alveolar
bone can grow during healing. The flap is
sutured over the wound, and postoperative
radiographs are obtained.3,22

Postoperative management
Pain control and wound care are accomplished
with analgesic medications and antiseptic oral gels.
Cats seem to tolerate the taste of zinc ascorbate
gel better than that of chlorhexidine gluconate
products.3 Soft food should be given for 2 weeks.
Cats with stomatitis undergoing partial or full-mouth
Figure 25 (A) Preoperative radiograph of the left maxillary canine tooth from Figure 24, tooth extraction may benefit from placement of an
showing root replacement resorption (asterisk). (B) Postoperative radiograph following crown
amputation, showing reduction of the resorbing root to about 12 mm below the level of the oesophagostomy feeding tube.23
alveolar margin (double-ended arrows)

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R E V I E W / Oral anatomy and tooth extraction

Avoidance and management force. it is more likely in the presence of


of complications severe periodontitis or other pathology that
has weakened the jaw bone. When occurring
The entire tooth must be removed in order to near the mandibular canine,27 the fracture
avoid complications such as local or systemic often is non-displaced, and creating two
infection.18,19 intraosseous sutures may be sufficient for
< Retained root remnantsif a root remnant healing.
cannot be retrieved, a note is made in the < Oronasal fistulaoronasal communication
dental record and the client informed about in the area of a missing maxillary canine
the complication. The surgical site should be tooth is rare in the cat. An acute oronasal
evaluated periodically by means of clinical fistula may be encountered during extraction
and radiographic follow-up examinations.11 of maxillary teeth and is managed by
< HemorrhageBleeding can usually be Repeated suturing a flap over the extraction site.3
controlled by means of digital pressure with wiggling < Bite traumaAfter extraction of a
a gauze swab. Severe bleeding is rare and maxillary canine tooth, the tight upper lip
likely due to injury of vessels in the motions during may position more palatally, allowing the
mandibular or infraorbital canal or the ispilateral mandibular canine tooth to bite
mucosa of the nasal cavity. Packing a small tooth extraction into it. Reducing the pointed tip of the
amount of bone wax into an alveolus is will crush and mandibular canine by 1 mm (be careful about
usually sufficient to stop excessive bleeding.3 pulp exposure!) is usually sufficient to solve
< Iatrogenic traumaRepeated brief soften adjacent the problem; exposed dentin should be
wiggling motions during tooth extraction treated with a layer of unfilled resin (dental
will crush and soften adjacent alveolar bone,
alveolar bone, adhesive) to reduce postoperative sensitivity.
making elevation of a tooth more difficult. making < EmphysemaEmphysema sometimes
Excessive leverage against adjacent teeth occurs after tooth sectioning or alveolectomy
should be avoided to prevent their elevation elevation of with air-driven high-speed equipment. This
or fracture. developing permanent teeth a tooth usually resolves spontaneously within days.
could be injured when extracting adjacent Air must never be blown into alveolar sockets
deciduous teeth.3 instrument slippage could more difficult. or onto bleeding surfaces, as it can cause air
cause local or distant soft tissue trauma or emboli.3,28
injury to the operator or assistant.2426 < Wound breakdownWound dehiscence
< Sublingual edemaiatrogenic trauma is primarily caused by tension on suture
or excessive pharyngeal packing can result lines. The wound can be resutured or is left
in sublingual edema. intravenous to granulate and epithelialize. A blood clot
dexamethasone may be administered if remaining in the alveolus, regardless of
respiratory compromise is present. whether or not the extraction site is sutured
< Sublingual sialoceleinjury to salivary closed, will avoid local infection and
ducts in sublingual tissues occasionally inflammation such as alveolar osteitis
causes a sublingual sialocele (ranula), which (dry socket).
is treated by marsupialization or resection of < Non-healing extraction siteif an
the sublingual and mandibular glands.3 extraction site is not healing, a biopsy is
< Mandibular fractureMandibular fracture warranted to rule out neoplasia.
is usually due to insufficient preparation Note that temporary bacteremia during and
prior to extraction (eg, important pathology after tooth extraction procedures is not an indi-
remaining undetected because radiographs cation for the perioperative use of systemic
were not obtained) or the use of excessive antibiotics in an otherwise healthy patient.3

KEY POINTS
< The veterinarian should be familiar with the tissues that hold the teeth in the jaws.
< The client must consent to the number of teeth to be removed prior to the procedure
being performed.
< Proper instrument handling is paramount in avoiding iatrogenic injury.
< Feline teeth are quite delicate and become brittle when affected by resorption.
< The entire tooth must be removed in order to avoid local or systemic infection.
< Tension is the most common reason for flap dehiscence.
< Roots remaining in the jaws must be recorded in the patients medical record.

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R E V I E W / Oral anatomy and tooth extraction

Funding bone in cats. Acta Cir Bras 2012; 27: 8287.


13 da Silva AM, Astolphi Rd, Perri SH, et al.
The authors received no specific grant from any Filling of extraction sockets of feline maxil-
funding agency in the public, commercial or not-for- lary canine teeth with autogenous bone or
profit sectors for the preparation of this article. bioactive glass. Acta Cir Bras 2013; 28:
856862.
Conflict of interest 14 deBowes LJ. Simple and surgical exodontia.
Vet Clin North Am Small Anim Pract 2005; 35:
The authors do not have any potential conflicts of 963984.
interest to declare. 15 Smith MM. The periosteal releasing incision.
J Vet Dent 2008; 25: 6568.
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