SECTION I8 • Dentistry
Frank J. M. Verstraete, Section Editor
CHAPTER
194
Applied Oral Anatomy and Histology
Abraham J. Bezuidenhout
GENERAL ANATOMY OF THE
ORAL CAVITY AND ADJACENT
STRUCTURES
The oral cavity of the dog and cat consists of two
comparbnents, namely, the oral vestibule and the oral cav-
ity proper. The oral vestibule is the space bounded laterally
(or labially/buccally) by the lips and cheeks and medially
(or palatally/lingually) by the gingiva and teeth. Caudal to
the last maxillary molar tooth, the underlying masseter
muscle forms a distinct bulge into the wall of the
vestibule. The oral vestibule is open to the exterior through
the rima oris (mouth). Dorsally and ventrally, the mucous
membrane lining the inside of the lips and cheeks reflects
onto the alveolar processes of the underlying hones to form
the alveolar mucosa. The dorsal line of reflection is some-
times referred to as the fornix of the vestibule. The thin
and nonkeratinized alveolar mucosa abruptly thickens at
the mucogingival junction to form the gingiva (see later).
The ducts of the parotid and zygomatic salivary glands
open into the vestibulum. In the dog, the opening of the
parotid duct lies on the parotid papilla, situated opposite
the distal part of the maxillary fourth premolar and approx-
imately halfway between the fornix and the mucogingival
junction. In the cat, the duct opens opposite the maxillary
third 10 or fourth"' premolar. The main duct of the zygomatic
gland opens on a small zygomatic papilla opposite the
caudal part of the maxillary first molar, near the fornix. A
number of accessory ducts from the zygomatic gland open
caudal to the main duct.
The oral cavity proper is the space between the dental
arches. It extends from the incisors rostrally to the palato-
glossal arch caudally. The roof of the cavity is formed by
the hard palate and the rostral part of the soft palate, the
lateral and rostral walls are formed by the teeth and gin-
giva, and the floor is formed by the tongue and the re-
flected mucosa under the tongue. The mucosa and submu-
cosal tissue of the roof are tightly adherent to the
underlying bone and form a series of transverse ridges or
rugae. A small, rounded incisive papilla is present in both
the dog and cat. lt lies just caudal to the maxillary first
2630
incisors and is confluent with the first transverse ridge. On
either side of the papilla are the openings of the incisive
ducts that connect the nasal cavity with the oral cavity.
The paired vomeronasal organs end in the incisive ducts.
Laterally and rostrally, the mucosa of the hard palate is
continuous with the mucosa of the gingiva. The thick,
.keratinized mucosa of the hard palate is tightly attached to
the bone, and there is no clear mucogingival junction. The
hard palate is supplied by the major palatine blood vessels
and is innervated by the major palatine nerves (sensory
from the maxillary division of the trigeminal nerve). The
blood vessels and nerves run together in a groove on the
ventral surface of the palatine process of t1te maxilla. They
emerge from the major palatine foramen opposite the distal
aspect of the maxillary fourth premolar (dog) or maxillary
third premolar (cat). In the dog, the vessels and nerves pass
rostrally, about halfway between the alveolar border and
the midline. In the cat, the blood vessels and nerves pass
rostromedially and are situated closer to the midline. The
soft palate is supplied by the minor palatine blood vessels
and nerves (sensory from the maxillary division of the
trigeminal nerve, motor from the vagus and glossopharyn-
geal nerves). When the mouth is closed, the tongue fills the
oral cavity proper. From the ventral surface of the tongue,
the mucous membrane is reflected laterally and rostrally
onto the alveolar processes of the mandible, completing the
floor of the cavity. The mucous membrane of the floor is
largely supported by the mylohyoid and geniohyoid mus-
cles. An extensive groove, the lateral sublingual recess, is
present between the ventral surface of the tongue and the
gingiva. The polystomatic sublingual salivary glands open
by a series of small openings into the recess. Rostrally, the
mucous membrane between the body of the tongue and the
floor forms a fold, the lingual frenulum. The ducts of the
mandibular and monostomatic sublingual salivary glands
open on the sublingual caruncles, which lie on either side
of the sublingual frenulum. In the dog, a distinct fold of
mucous membrane, the sublingual fold, extends caudally
from the sublingual caruncle to the mandibular first molar.
The fold lies ncar the body of the mandible and is formed
by the ducts of the mandibular and monostomatic sublin-
gual salivary glands as well as a variable number of poly-

stomatic sublingual salivary gland lobules. Branches of the
sublingual blood vessels and the sublingual nerve accom-
pany the ducts. In the cat, a prominent masslike flap of
mucosa containing a small mixed salivary gland lies just
medial to the mandibular lirst molar. 11
At the root of the tongue, a fold of mucous membrane,
the palatoglossal arch, extends from the lateral surfaces of
the tongue to the soft palate. The arch designates the cau-
dal limit of the oral cavity and the beginning of the oro-
pharynx. The soft palate forms the roof, the fauces the
lateral walls, and the root of the tongue the ftoor of the
oropharynx. The fauces is defined as the area of the phar-
ynx caudal to the palatoglossal arches where the tonsils arc
located. The oropharynx is innervated by the glossopharyn-
geal nerve.
DEVELOPMENT AND ERUPTION
OF TEETH
Development
In the developing cat or dog embryo, extensive cellular
interactions result in proliferation, migration, and differenti-
ation of tissues. 15 Interactions between the oral ectoderm
and the underlying neural crest-derived mesenchyme result
in proliferation and thickening of the epithelium along the
outer edges of the mandibular and maxillary processes. The
deep surface of this thickened epithelium grows into the
underlying mesenchyme, thereby fonning two thickened
epithelial arches or laminae. The lateral arch is the labi-
ogingival/labiobuccal lamina, and the medial arch is the
dental lamina. The lateral arch develops by day 30 and
then forms an invagination or groove, resulting in the sepa-
ration of the bucca and gingiva and the formation of the
oral vestibule. 1
The dental lamina develops in the region of the future
alveolar processes. In the dog, the dental laminae are first
apparent on day 25 of development, and by day 30, the
left and right laminae are joined rostrally across the mid-
line, forming a complete dental arch. Localized invagina-
tion and cellular proliferation of the dental lamina at the
sites of future deciduous teeth result in a series of rounded
or oval swellings, the dental or tooth buds. The underlying
mesenchyme also aggregates and condenses. The tooth
buds continue to proliferate and penetrate deeper into the
mesenchyme. Tooth buds for permanent teeth that will re-
place the deciduous teeth develop lingual to the deciduous
tooth buds. They bud from the deeper part of the dental
lamina between the surface epithelium and the deciduous
tooth buds. Tooth buds for the molar teeth develop directly
from the dental lamina. The permanent first premolar of
the dog is exceptional and is not preceded hy a deciduous
premolar. 1 Excessive or uncontrolled budding leads to the
development of supernumerary teeth. The developing alve-
olar processes of the maxillary and mandibular jaws grow
around the tooth buds, incorporating them into the bone.
Further development of the tooth is a continuous process
characterized by different morphological stages of the epi-
thelial component. Bud, early cap, cap, advanced cap, early
bell, and advanced bell stages are recognized. 1 A simplifi-
Applied Oral Anatomy and Histology 2631
cation of the stages recognizes the bud, cap, and bell stages
(Fig. 194-1).
With continued expansion, the distal surface of the tooth
bud gradually becomes concave, resulting in a cup-shaped
dental or enan1el organ that partially surrounds the neural
crest-derived mesenchymal dental papilla. With further de-
velopment, the connection between the dental lamina and
the dental organ gradually degenerates and is finally lost. A
condensed layer of mesenchyme, the dental follicle or den-
tal sac, now surrounds the dental organ and dental papilla.
This completes the cap stage in which the dental follicle,
dental organ, and dental papilla are defined.
During the bell stage, the epithelium and mesenchyme
difl'erentiate through intermediate stages into the final tis-
sues of the dental organ. The formation of a. mineralized
tooth depends on the reciprocal interactions between the
dental organ epithelium and the mesenchyme of the dental
papilla. The epithelium of the dental organ differentiates
into four layers, the outer dental enamel epithelium, a stel-
late reticulum, an intermediate layer, and the inner dental
enamel epithelium. The inner dental epithelium differenti-
ates into ameloblasts that produce enamel in the direction
of the dental papilla. The mesenchyme of the dental papilla
in contact with the inner dental epithelium differentiates
into odontoblasts that produce dentin in the direction of the
dental organ. The rest of the dental papilla remains as the
dental pulp. The enamel therefore grows outward and the
dentin inward, giving rise to the formation of the crown
and reducing the size of the dental pulp. The surrounding
dental follicle differentiates into cementoblasts that produce
cementum, osteoblasts that produce alveolar bone, and the
periodontal ligament. The earliest tooth to develop is the
mandibular first molar. Calcification begins at day 42 and
enamel production early in the eighth week of development
in the dog, slightly earlier in the cat. A definite pattern of
calcification unrelated to eruption succession exists for the
deciduous dentition of the dog.l 1
Root formation begins early in eruption of the tooth and
continues rapidly until the final position of the tooth is
reached. 7 The outer and inner dental epithelium around the
distal (deep) edge of the dental organ proliferates to form
Hertwig's root sheath. The inner layer of the root sheath
induces the adjacent dental papilla to differentiate into
odontoblasts, which produce dentin of the root; the sur-
rounding dental follicle produces the periodontal ligament
and a thin layer of cementum on the surface of the root.
The distal end of the root sheath forms the epithelial dia-
phragm that surrounds the apical opening. Jn teeth with
more than one root, the developing root sheath divides into
two or three root sheaths that grow distally from the crown
of the tooth. Excessive division of the root sheath results in
supernumerary roots. 1
The external dental epithelium, together with the internal
dental epithelium after these cells have completed their
function as ameloblasts, eventually forms the reduced den-
tal epithelium. Clusters of epithelial cells remaining in the
developing periodontal ligament after the epithelial root
sheath has broken up are known as the epithelial rests of
Malassez. The periodontal ligament originates from the
dental follicle. When the tooth erupts, the reduced dental
epithelium becomes the junctional epithelium.
2632 Dentistry

dental papilla and

Benamel II dentin D dental pulp

oral epithelium dental Cap

Bud
_ s)c--
V
A
lamina

B
enamel
organ C 7
degenerating dental lamina dental pop;llo _ _ /

Bell bud of
enamel
reticulum
J/ ; tooth
dental
and

D
- outer
enamel
epithelia E
-T'i'lif---- papilla

epithelial
root sheath
F
I epithelium

Figure I 94- I . Developmental stages and eruption of a simple deciduous tooth and the concurrent development of its permanent counterpart. (From
Moore KL: The De,•eloping Human : Clinically Oriemed Embryology, 6th ed. WB Saunders. Phi ladelphia. 1998, p 524.)

Eruption
The rate of eruption of teeth shows three phases, an
initial slow eruption through the bone, a rapid eruption
once the tooth is above the alveolar crest, and a slow phase
after the tooth reaches the occlusal plane.7 Tooth eruption
consists of a local coordination of alveolar bone resorption
at the coronal aspect of the tooth, forming an eruption
pathway, and concomitant bone formation at the apical
aspect of the tooth. The dental follicle plays a critical role
in the process. Development and elongation of the roots of
teeth do not play any role in eruption. Not all the teeth
erupt at the same time, and various authors give different
times for the eruption of deciduous and permanent teeth of
the dog andl cat. Variation occurs with breed and size of
the animal, and gingival eruption is followed by extrusion
to full crown height during a period of several weeks. Both
the cat and the dog are born edentulollls. Table 194-1
gives the times of eruption for the dog and cat. 4
MICROSCOPIC STRUCTURE OF
TEETH
The basic histological structures of the simple tooth are
enamel, dentin, pulp, and cementum, arranged in a definite
pattern (Fig. 194-2). Enamel, produced by the ameloblasts
of the developing tooth, is the outer covering of the crown.
lt is the hardest substance found in the body, approxi-
mately 0.2 mm thick in the cat, 0.5 to I mm in the dog;
96% to 99% of its weight is mineral in the form of hy-
droxyapatite crystals, and the other l % to 4% consists of
organic matrix. 14• 16 The enamel consists of thin enamel
rods or prisms; the areas between the rods are filled with
 Applied Oral Anatomy and Histology 2633

interrod enamel. Three enamel layers are present in the dog

and cat, a surface rodless (aprismatic) layer. an outer layer
of parallel rods, and an inner layer of variable rods that
frequently change their direction. 14 The enamel on the la-
bial surfaces of the canines of the cat are grooved.
Dentin is produced by the odontoblasts and is similar to
bone in structure but considerably harder. It forms the bulk CROWN
of the crown and root and is covered by either enamel or
cement. Primary dentin is produced until the external form
of the tooth is completed. Dentin is 20% to 30% organic
matter, of which 92% is collagen; the 70% to 80% inor-
ganic portion consists mainly of hydroxyapatite crys-
tals.14· 111 Dentin has a radially striated appearance from the Mit--free
presence of minute parallel dentin tubules that radiate from gingiva
the pulp cavity to the dentinoenamel junction. Each tubule
contains a long odontoblast process. The odontoblasts re-
lease their secretory products (mainly protocollagen) from
their apical surfaces. The protocollagen polymerizes, form-
ROOT
ing a layer of unmineralized predentin around the proximal
portions of the odontoblast processes. There is an abrupt
transition from predentin to mineralized dentin, forming a
distinct mineralization front. Mineralization of developing
j
dentin appears as globular aggregations of apatite crystals
along or within the collagen fibers. The aggregations grad- Figure 194-2. The anatomy of a nonnal tooth illusLrating the relation·
ually enlarge and coalesce. This process is not uniform, \hlp of 11\\ues, including enamel. denun. pulp chamber, root canal. and
and occasional angular spaces containing only organic ma- penodontal ligament.
trix persist. These unmineralized globular spaces are found
in the deeper parts of the crown but are more common in
the root, where they persist as the granular layer of Tomes. vessels are also present. Bundles of myelinated afferent
A modified type of dentin (reparative or tertiary dentin) is nerves enter the pulp through the apical foramina and form
found in older teeth along the pulp cavity wall or ncar a plexus in the pulp.
areas of attrition or abrasion. Cementum covers the root of the tooth and meets the
Secondary dentin continues to be formed slowly after enamel in an abrupt transition, the cementoenamel junction,
eruption of the tooth, and the pulp cavity is progressively at the alveolar margin of the crown. It is a thin layer of
narrowed. Whereas enamel is insensitive, dentin is sensitive mineralized tissue that rcsemblel> bone in composition and
to some '>timuli. A few nerve fibers penetrate for a short structure. The layer consists of a calcified matrix of colla-
distance into the dentin. The odontoblast processes may gen fibers, glycoproteins, and mucopolysaccharides. Ce-
transmit stimuli from the dentin to the pulp. mentum is produced by cementoblasts, osteoblast-like cells
The pulp is the soft tissue of the tooth. It fills the enclosed in lacunae in the matrix. A thin layer of primary
coronal pulp cavity and root canal. Apart from the odonto- cementum adjacent to the dentin is acellular; the rest is
blasts that line the cavity, it retains some of the character- cellular cementum. It is mostly avascular, but as it in-
istics of mesenchyme, consisting of stellate cells that form creases in thickness with age, it may become vascular and
a three-dimensional cellular reticulum. Lymphocytes, mac- develop haversian systems. 111 Primary cementum is pro-
rophages, plasma cells, and eosinophils are present in lim- duced during eruption of the tooth; secondary cementum is
ited numbers. The gelatinous interstitium contains ran- produced throughout life. It is slowly growing and thicker
domly oriented collagen fibrils. Small arterioles enter and toward the apex of the root.
venules leave the pulp through the apical foramina. Capil-
lary branches ramify close to the bases of the odontoblasts,
and arteriovenous anastomoses are common. Lymphatic PERIODONTIUM

In a broader sense, the periodontium includes all the

Table 194- 1 . Tooth Eruption Times
tissues investing and supporting the teeth, that is, cemen-
tum, periodontal ligament, periodontal surface of the alveo-
Permanent lar bone, and gingiva at the dentogingival junction.
Deciduous Teeth Teeth The thin alveolar mucosa abruptly thickens at the muco-
(weeks) (months) gingival junction to form the gingiva. This part of the
Dog Cat Dog Cat gingiva consists of stratified squamous epithelium and is
tightly adherent to the underlying bone and is referred to
lnCI\01'\ 3- 4 2 3 3- 5 3- 4 as the attached gingiva. The gingiva projects beyond the
Canmes 3 3- 4 4 6 4- 5 alveolar margin of the bone, forming a short but distinct
Premolars 4- 12 3- 6 4- 6 4- 6
Mol an. 5- 7 4-5 free gingiva. Distally, at the gingival margin, the mucous
membrane reflects internally, forming a narrow gingival
2634 Dentistry
Cemen.tum - · ·j
Dentm - - - - ··
Pulp ---++---+--
Apical terminus
Apical
ramifications
]
"Apical delta"
Figure 194-3. The TOOt of a tooth illustrating the fonnation of an
apical delta. (From Verstraete PJM: Self-Assessment Color Review of
Veterinary Dentisrry. Iowa State University Press, Ames, Iowa, 1999, p
36.)
sulcus between the gingiva and the tooth. The groove sur-
rounds each tooth and is 2 to 3 mm deep in a healthy dog,
0 to I mm in the cat. In comparison with other carnivores,
the gingiva] sulcus of the cat is narrow. The epithelium
lining the gingival sulcus is nonkeratinized and thinner
than the rest of the gingival epithelium. It attaches to the
enamel, to the cementoenamel junction, or to the cement of
the tooth, depending on the age and periodontal health of
the animal.J7 This epithelial attachment is broad in the cat.
Between successive teeth, the gingiva forms short projec-
tions, the interdental papillae.
BONE
The mandible, maxilla, and incisive bones bear alveolar
processes. An alveolar process consists of a layer of can-
cellous bone between two layers of cortical bone. Each
alveolar process bears alveoli or sockets for the roots of
the teeth. The sockets are lined by a thin layer of perfora-
ted cortical bone seen on radiographs as a lamina dura
dentis. 16 The lamina is perforated by numerous small ca-
nals that contain blood vessels, nerves, and lymphatics to
and from the apex and periodontal ligament of the tooth.
Tnteralveolar septa separate one alveolus from another; in-
terradicular septa separate one root from another in the
same socket. Teeth are firmly anchored to their sockets by
the periodontal ligament. The ligament consists of a variety
of cells and a dense layer of collagen between the cemen-
tum and the surrounding alveolar bone. Coarse collagen
fibers pass obliquely from their attachment on the alveolar
bone to a more apical attachment in the cementum of the
root.fi The arrangement of the fibers is such that pressure
on the tooth applies tension to the fibers inserting into the
bone. The orientation of the fibers varies at different levels
along the root.
PARTS OF THE TOOTH
Each tooth is divided into a crown, neck, and root. The
crown is that part of the tooth that protrudes above the
gingiva and consists of dentin covered with enamel. The
neck is a slight constriction of the tooth at the gingival line
where the enamel ends. The root is the portion of the tooth
below the gingiva and consists of dentin covered with
cementum. The pointed end of the root is the apex. The
pulp cavity consists of a pulp chamber in the crown and
the root canal in the root. In young animals, the root canal
is spacious and open distally, but continued deposition of
dentin by odontoblasts progressively narrows the canal to
form a root apex. In the dog8 and the root canal
divides into a number of smaller canals, forming an apical
delta instead of an apical foramen for the passage of blood
vessels and nerves (Fig. 194-3).
NOMENCLATURE AND
CLASSIFICATION OF TEETH
The terminology used in the classification and number-
ing of teeth is derived mainly from h11man anatomical
nomenclature. Humans lack an incisive bone; consequently,
all the teeth in the superior dental arcade are borne in the
maxilla and are referred to as maxillary teeth. In veterinary
dentistry, this presents a problem because the incisors and
canine teeth of the superior dental arcade are borne in the
incisive bone. Although anatomically incorrect, the term
maxillary teeth is also used in referring to all the teeth of
the superior dental arcade of domestic animals.
To describe the surfaces and direction relative to the
tooth or to the rest of the dentition accurately, standardized
terminology must be used (Fig. 194-4). The following
terms are anglicized versions of tenns from Nomina Ana-
tomica Veterinaria3 :
occlusal surface: the chewing surface
vestibular surface: the outer surface or the surface facing
the vestibulum
lingual surface: the inner surface or the surface facing the
tongue
contact surface: the sutface in contact with another tooth in
the same dental arch. The term is further subdivided into
a mesial surface, the surface toward the midline between
the first incisors, and a distal surface, the surface away
from the first incisor.
Other generally accepted terms are
apical: toward the apex of the root
coronal: toward the crown of the tooth
interproximal: the adjacent surfaces of two teeth
incisal: the biting surface of incisors
The classification of teeth is based on their shape and
Figure 194-4. Positional tcmtinology used to lks.:ribe the surfaces of
the tooth and direction relative to the tooth or to the rest of the dentition.

the interrelationship of their various anatomical parts. The
dog and cat have simple, tube rculate teeth with well-devel-
oped roots. Their dentition can be described as diphyodont
(!he deciduous teeth are replaced by pennanent teeth),
brachyodont (the roots are longer than the crowns), hetero-
dont (the of the various teeth differs). and anelodont
(the teelh are fu lly formed at the time that they erupt and
do not grow continuously).
Four types of teeth are recognized, depe nding on the
general shape and presumed function. They are the incisors
(I), canines (C), premolars (P), and molars (M ) (Fig. 194 -
5). Teeth are numbered starting from the midline of the
maxillary and mandibular jaws . Collective ly, the teeth of
the maxillary jaw form the superior dental arch, and !hose
of the mandibular jaw the inferior dental arch.
Incisors
The incisors have distinct crowns, necks, and roots.
They increase in size from the first to !he third, and the
maxillary incisors are larger than the mandibular ones. All
incisors have. one root, and the roots of the mandibular
incisors of the dog are flattened mesiodistally. The occlusal
surfaces of !he maxillary incisors bear three tubercles, a
large central tubercle and two smaller ones. The mandibu-
lar incisors bear a large central tubercle and one small
tubercle distally. The maxillary third incisor of the dog is
triangular in cross-section, and its root apex lies adjacent to
the nasal cavity. The incisors of the cat arc similar to those
of the dog, but considerably smaller.
Canines
The canines are the largest teeth. They lack a distinct
neck, and the single roots are generally longer than the
crowns. T be crowns have a slight distal curve, and in the
S8[J
... .;
Figure 794-5. Dental charts of the permanent dentition of the dog ami cat. (From Holmstrom SE, eta!: Veterinary l>enra/ Techniques. WB Saunder..,
Philadelphia, !992. p II.)
Applied Oral Anatomy and Histo logy 26J5
cat, the maxillary canines have a mesial inclination. 17 In
the cat, the crowns of bolh mandibular and maxillary ca-
nines are grooved along the labial surfaces, and they end in
sharp points. In the dog, they are smooth, and the ends are
blunted.
The root apex of the mandibular canine tooth lies medial
to the middle mental foramen. The root of the maxillary
canine is separated from the nasal cavity by a thin plate of
bone, and laterally it forms a low ridge on the vestibular
mucosa, making it possible to palpate the extent of the
root.
Premolars
In the dog, the first premolars are small and single
rooted; they erupt late and are not replaced. The mandibu-
lar second, third, and fourth premolars have two roots; the
maxillary fourth premolar has three roots, two mesially and
one large root distally. The distal root of the maxillary
third premolar lies ventral to the infraorbital fommen; the
mesiobuccal and distal roots of the maxillary fourth premo-
lar lie ventrolateral to the infraorbital canal. Dogs lack a
true maxillary sinus but have a large maxillary recess. The
apices of the distal root of the maxillary third premolar and
the mesiopalatine root of the maxillary fourth molar lie in
the lateral wall of the recess, separated from the nasal
cavity by a thin plate of bone.
Cats lack first and mandihular second premolars; there-
fore, the first premolars seen are the second premolars in
tht! maxilla and the lhird premolars in the mandible. The
maxillary second premolars are small and mostly single
rooted, but double or fused roots are occasionally seen. 18
The third premolars and the mandibular fourth premolars
are larger and typically have two roots of about the same
size. Approximately 10% of maxillary third premolars have
a small third root on the palatal aspect. 18 The maxillary
fourth premolar is twice the size of the preceding premolar
Buccal
Ocausel Q Q IC7G>G QOE) Q 410> <9J G)
Palatal a tJ tJ
Ungual \j (j ?\fw
Q QC>G> &>C>C> Q
2636 Dentistry
and has three roots, two mesially and one large root dis-
tally.
Molars
In the dog, two maxillary and three mandibular molars
are present. Both maxillary molars have flattened occlusal
surfaces and three roots, two smaller vestibular roots and
one larger lingual root. The mandibular first molar is large
and has two roots. A mesial root supp011s a large central
cusp and a smaller mesial cusp on the crown, and a
smaller distal root supports the mandibular and flattened
distal part of the crown. The second molar is reduced with
a flattened occlusal surface and two roots. The mandibular
third molar is rudimentary with a single root.
The cat has one rudimentary maxillary molar. It gener-
ally has two roots, one larger vestibular root and a smaller
lingual root, but anatomical variations are common. 18 The
mandibular first molar is distinctly different from the pre-
ceding fourth premolar; it has two prominent cusps and
two roots, a large mesial root, and a small distal root that
is often curved distally.
Deciduous Dentition
Deciduous teeth are morphologically similar to their per-
manent counterparts but smaller and slimmer. The decidu-
ous premolars resemble the permanent teeth distal to them
(e.g., the shape of the deciduous fourth premolar is similar
to the permanent first molar).
Dental Formulas
The dentition of the dog and cat can be expressed in a
dental fonnula using the abbreviation of the tooth followed
by the number of teeth represented in the maxilla and
mandible. Deciduous dentition is indicated by lowercase
letters, permanent teeth by uppercase letters.
Dog, deciduous:
Dog, permanent:
CaL, deciduous:
Cat, permanent:
Dental Numbering Systems
A number of tooth identification and numbering systems
can be used in a dental record instead of anatomical abbre-
viations. One commonly used method is the Triadan sys-
tem. In this system, each tooth has a three-digit number.
The first number represents the quadranL, the right maxilla
being 1, left maxilla 2, left mandible 3, and right mandible
4. The individual teeth arc represented by two digits, with
the first incisor being 01 and continuing distally. For exam-
ple, the left maxillary fourth premolar is noted as 20R. The
numbering of the deciduous dentition begins with 5/6/7/8.
VASCULARIZATION AND
INNERVATION OF TEETH
(Fig. 194-6)
The teeth of the maxillary jaw are innervated by the
maxillary division of the u·igeminal nerve. From the alar
canal, the maxillary nerve passes rostrally on the dorsal
surface of the medial pterygoid muscle, .iust ventral to the
periorbita. On reaching the pterygopalatine fossa, it gives
off the major and minor palatine nerves to the hard and
soft palates, respectively, and continues as the infraorbital
nerve. Caudal superior alveolar branches leave the ventral
surface of the infraorbital nerve and enter maxillary alveo-
lar canals through alveolar foramina to supply the caudal
maxillary teeth (mainly the molars). Each alveolar canal
leads to the apex of a root, where the nerve fibers enter the
pulp. After giving off the caudal superior alveolar nerves,
the infraorbital nerve enters the infraorbital canal through
the maxillary foramen. Within the canal, it gives off mid-
dle superior alveolar branches, which enter alveolar canals
through alveolar foramina to supply lhe maxillary third and
fourth premolars. Just before lhe infraorbital nerve leaves
the canal through the infraorbital foramen, it gives off the
well-defined rostral superior alveolar branch. This branch
enters the incisivomaxillary canal passing rostrally through
the maxilla and incisive bone to supply the first, second,
and third premolars as well as the canine and incisors.
The maxillary artery passes through the alar canal, where
it joins the maxillary nerve. It gives off branches that
accompany all the branches of the maxillary nerve, includ-
ing branches to the maxillary teeth, palate, and gingiva.
Figure 194-6. Diagrammatic representation of lhe blood vessels or
nerves on a sculptured canine skull. (Courtesy of H. E. Evans, Ithaca,
N.Y.)

The teeth of the mandible arc supplied by the mandibu-
lar division of the trigeminal nerve. The nerve leaves the
cranium through the oval foramen, passes between the lat-
eral and medial pterygoid muscles, and divides into a num-
ber of branches. Of these. the lingual netve supplies the
tongue and the tloor of the mouth, the buccal nerve sup-
plies the mucosa of the cheek. and the inferior alveolar
nerve supplies the teeth. Close to its origin from the man-
dibular nerve. the inferior alveolar nerve usually gives off
the mylohyoid nerve. This runs distally medial to the ra-
mus of the mandible to innervate the mylohyoid muscle
and the rostral belly of the digaslrie muscle as well as the
skin in the rostral two thirds of the intcrmandibular region.
The inferior alveolar nerve enters the mandibular foramen
and passes ros trally in the mandibular canal, giving off
caudal and middle inferior alveolar nerves to the mandibu-
lar molar and premolar teeth, and the rostral inferior alveo-
lar nerve to tlte mandibular canine and incisors. Near the
rostral end of the mandible, sensory branches of the infe-
rior alveolar nerve exit the three mental foramina (caudal,
middle. and rostral) to innervate the skin of the lower lip
and the intermandihular area rostral to the area supplied by
the mylohyoid nerve. The inferior alveolar artery accompa-
nies the nerve through the canal to supply all the mandibu-
lar teeth along its course.
The mandibular foramen lies just ventral to a line from
the temporomandibular joint lo the third mo lar tooth and
about halfway between the angular process and the man-
dibular third molar. From the foramen, the mandibular ca-
nal passes rostroventrally, close to the ventral border of the
mandible. In medium-sized dogs, the root apices of the
and first molar abut the dorsal sutface of the
canal; the apex of the can ine tooth lies medial to it. In
large dogs, more bone is present between the apices and
the mandibular canal; in small dogs, the roots occupy al-
most the entire height of tlle mandible.
NORMAL OCCLUSION
Dental Occlusion in the Dogn. 16
The dental occlusion of dogs depends to a large degree
on the breed of the dog, but most dogs show the following
characteristics. When the jaws are closed. the maxillary
incisors lie rostral to the mandibular incisors such that the
vestibular surfaces of the mandibular incisors touch the
lingual surfaces just coronal to the gingival margin (or
cingulum) of the maxillary incisors. The mandibular canine
fits in the space between the maxillary canine and the
maxillary third incisor without touching them. The premo-
lars are alternately arranged such that the crown of a max-
illary premolar fits in the interdental space between two
mandibular premolars. The mandibular first premolar is the
most rostral of the premolars, and its crown fits in the
space between the maxillary canine and first premolar. The
maxillary fourth premolar lies opposite the mandibular first
molar, and when the mouth is closed, its crown passes the
vestibular surface of the mandibular first molar, forming a
shearing mechanism.
Applied Oral Anatomy and Histology 2637
Dental Occlusion in the Cat 4 · 17
When the j aw is closed, the mandibular incisors nor-
mally strike the caudal surface of the maxillary incisors or
immediately caudal to them. T he mandibular canine oc-
cludes between the maxillary third incisor and the maxil-
lary canine. Because the maxilla is wider than the mandi-
ble, the mandibular premolars and molars are nearer the
sagittal plane of the skull than are the maxillary teeth. The
maxillary and mandibular teeth do not touch when the jaws
arc moved in an absolute vcnical line. To chew on one
side of the mouth, the mandible must be brought to that
side, so the vestibular surface o f the mandibular teeth may
shear upward and forward against the lingual surface of the
maxillary Leeth. The mandibular third premolar lies rostra}
to the maxillary third premolar; the same app lies to the
fourth premolars. The maxillary fourth premolar covers the
vestibular surface of the mandibular first molar from mesial
to distal.
References
I. HE: The and abdomen. In Evans liE (cd):
Miller' s Af!atomy of the Dog. WB Suunders, Philadelphia, 1993, p
385.
2. Fawecu DW: The teeth. In OW (cd): A Te.xrbook. Histo/-
ozy. Chapman and Hall, New York, 1993. p 578.
3. Habel RE: In Prewein J, ct al Nomina Anarom-
ica Verainaria. Tnternational Committees on VeLerinary Gross Ana-
tomical Nomenelamre, Veterinary Histological Nomenclature, and
Veterin ary Embryological Nomenclature, Zurk h . 1994, p 42.
4. Harvey CE . Emily PP: Function. fonnation, and anatomy of oral
strucrures in carnivores. ln Harvey CE. Emily PP (eds): Small Animal
lJenri.!try. \1o.<by. St. Louis, 1993, p I.
5. Hennet PR, Harvey CE: Apical root canal anatomy of canine teeth in
cats. Am J Vet Res 57: 1545, 1996.
6. Lawson DD, ct al: Dental anatomy and hi stology of the dog. Rt>.s Vel
Sd 1:'201, 1960.
7. Marks SC, HE: Tooth eruption: Thc:ories an d facts. Anar
Rec 245:374. 1996.
8. 1::, et al: Apical root cannl anatomy in the dug. Endod Dent
Traumaro /8: 109. 1992.
9. Mi vart St G: The eat 's alimentary system. Tn Mivart St G (w): The
Cat. John Murray, London, 1881, p 165.
10. Nickel R, ct al: Digestive system. In Nickel R, et al (eds): Thf.
Viscera of the Domesric Mammals. Verlag Paul Parey, Berlin, I979. p
21.
II. Okuda A, et al: The membranous hu1ge lingual to the mandibular
mvlar t.ood! of a cat contains a small salivary gland. J Vet Dent 13:
61. t 996.
12. Orsini P, Hennet P: Anatomy of the mouth and teeth of the cat. Ver
Clin North Am Small Anim Pracl 22: 1265, 1992.
13. RO$ DL: Orthodontics for the dog- bite evalu ation, ha.sic concepts,
and equipment. Ver Clin North Am Small Anim Pract 16:955, 19!16 .
14. Skobe Z, et al: Scanning electron microscope study of cat and dog
enamel structure . .I Morpho/ 184: 195, 1985.
15. Theslcff I, Hurmerinta K: interactions in tooth dcvclopmt'nt.
Oifferenriation 18:75, 198L
16. van Foreest A: Aanleg, bouw en fun ctie van hct gebit van de hcnd.
Tijdschr DiergeJZeeskd 116:1007, 1991.
17. van Foreest A: bouw en functie VIII! hct gehit van de km.
Tijdschr Diergenee.vkd 120:3, 1995.
IS . Verstraete FJM, Terpak CH: Anatomical in the dentition of
tb c cat. 1 Vt•t Dent 14: 137. 1997.
C H A P T E R
195
Oral Pathology
Frank J. M. Verstraete
DEVELOPMENTAL ANOMALIES
OF TEETH
Many disturbances of the development and growth of
oral structures and teeth have been recognized in the dog
and cat. These dental disturbances may be manifested as
abnormalities of shape, number, eruption and exfoliation,
or structure. In addition, a number of occlusal problems
may occur. These dental anomalies may have a genetic
background or be caused by environmental factors interfer -
ing with fetal or neonatal 132 In humans,
hereditary factors and pathological envirorunental condi-
tions account for about 10% of developmental anomalies,
and the remruning 80% are idiopathic. 1o4
Abnormal Shape
Gemination, Fusion, and
Concrescence
Gemination, fusion, and concrescence are developmental
disturbances in the shape of teeth.6 1. 70• Gemination (or
dichotomy) refers to an attempt at division of a single
tooth bud. This attempt results in the incomplete formation
of two teeth. The clinical appearance is usually that of a
tooth with a longitudinal coronal groove and a single root.
Fusion and concrescence of teeth denote a joining of two
tooth buds to form a single structure. Fusion may be com-
plete or incomplete, but the dentin is always confluent. In
concrescence, the teeth involved have completely separated
dentin, but the cementum of the roots is confluent. Fusio n
can affect two normally present teeth but can also occur
between a normal tooth and a supernumerary tooth. It may
be difficult or impossible to differentiate between fused and
dichotomous 70• Hl4
These anomalies are rare. Colyerl8 found gemination in
the dog and in 12 wild animal species. Most epidemiologi-
cal studies on the dental disorder:> of the dog and the cal
do not mention fu sion or gemination of teeth.77. so, 82, 96
Kuiper and associates66 described two cases of incisor gem-
ination and one case of suspected fusion in the dog. One
case of premolar gemination was found in a series of 155
cats. 124
Most documented dichotomous teeth in the dog involve
incisor rH,
66
although gemination or fusion involving
the maxillary third premolar in a dog and in a cat has been
rccorded. 118 In animals, geminated or fused teeth are usu-
ally of academic interest only, especially when the incisors
2638
are affected. They may give ri:>e to periodontitis as a result
of the altered gingival contour and occlusal trauma, and
malocclusion may be prescm. 118 ·Extraction may be indi-
cated.
Dilaceration, Supernumerary Roots,
and Fused Roots
Dilaceration is a sharp curve in the root, which is proba-
bly caused by trauma to the dental genn. 104 Root dilacera-
tion is relative ly common in the dog, with a reported prev-
alence of 3.5%, but rare in the cat. 121• 122 Supernumerary
roots are anatomical variations that are occasionally seen in
the dog and cat and that mainly affect the maxillary pre-
molars, and the third premolar in particular (Fig. 195-
1A) .121. 122 The prevalence of three-rooted maxillary premo-
lars in the cat was 10.3%.124 Fused roots are common in
dogs, with a prevalence of 23%, and typically involve the
premolars. 122 Dilaceration, supernumerary roots, and fused
roots may be clinically important if extraction of the in-
volved teeth is indicated.
Other Abnormalities
The Lerro de ns-in-dente refers to a well-recognized devel-
opmental abnormality in humans characterized by an in-
vagination of the enamel and dentin from the surface. of
the tooth crown. 104 Food impaction and caries may arise.
This condition has been mentioned in animals.94 Enamel
pearls have been described in the dog.w An enamel pearl is
a small, focal, excessive mass of enamel on the surface of
the tooth, most frequently near the cemcntoenamel junction
or in the bifurcation of dental roots.
Abnormal Number
Anodontia, Oligodontia, and
Hypodontia
Anodontia is the complete congenital absence of teeth,
which may involve both the deciduous and the permanent
dentition. This condition is extremely rare in dogs and
cats.4 • 115 Hypodontia, or partial anodontia, is congenital
absence of one or more teeth. This condition is com-
mon.4· 18 Oligodontia is a more severe form of hypodontia
and implies that only a few teeth are present. 9 1 Anodontia,
hypodontia, and oligodontia are differentiated from false
anodontia, hypodontia, and oligodontia-or pseudoanodon-

Figure 195- 1. Abnonnal shape and number of teeth. A, Maxillary
th1rd premolar with a supernumerary root in a cat. 8, Supernumerary
maxillary first molar (mt•) m a dog causing incomplete eruption of the
fourth premolar (p4). mI. maxillary first molar.
tia, pseudohypodontia, and pseudo-oligodontia- which in-
volve absence of teeth as a result of extraction, trauma,
periodontitis, or failure to erupt.
Hypodontia is much more common in the permanent
dentition than in the deciduous dentition. 94 If deciduous
teeth are missing, the corresponding permanent teeth are
likely to be absen t.94 The first premolar and the third molar
are most often affected in the dog. 27· 82 The maxillary sec-
ond premolar in the cat has been the subject of consider-
able investigation, and the absence of this small tooth is
common in certain populations. 77 • ?8. 124
Hypodontia is usually considered a serious fault in show
and breeding dogs, and radiographic techniques have been
described for the early diagnosis of missing teeth. 211 Hypo-
dontia is not a recent development- it occurred in prehis-
toric dogs.•• The genetic implications of hypodontia are
complex. 107· 132
Polyodontia
Polyodontia, or supernumerary teeth, is possibly less
common than missing teeth,4• 82 yet a prevalence of 11%
and 13% was noted in two studies in dogs. 66· 122 Certain
breed variations have been In both humans
Oral Pathology 2639
and dogs, supernumerary teeth are more common on the
maxilla. 4 A supernumerary premolar mesial to the first pre-
molar and a supernumerary molar distal to the last molar
are most common in dogs and arc of minimal clinical
importance. 66· 82. 107 A well-recognized entity is the mesio-
dens, which is a supernumerary maxillary incisor found
between the first two incisors. The prevalence of the
mesiodens was 39% and 26% in the bulldog and boxer,
respectively. 2 Supernumerary teeth in the middle of the
premolar and molar row are extremely rare. These teeth
may cause malocclusion and crowding as well as incom-
plete eruption or impaction of adjacent teeth (Fig. 195 -
I B). Although a genetic cause has been suggested, the
pathogenesis of polyodontia remains unclear.66· t07. m
Abnormal Eruption and
Exfoliation
Persistent Deciduous Teeth
Delayed exfoliation of deciduous incisors and canine
teeth is common in dogs, especially in toy breeds, and it
occurs in cats. 13· m Deciduous teeth may persist after the
eruption of the permanent teeth. "Retained" deciduous teeth
is a common misnomer for this condition; retained refers to
a failure to erupt, whereas persistent implies tlhe failure to
exfoliate. A strong genetic basis for this condition has been
suggested, although the exact pattern is undetennined.27. t32
A multifactorial pathogenesis, as in humans, should be
considered. 104
A deciduous tooth may persist because of the absence of
the corresponding permanent tooth and resulting incom-
plete root resorption. 4 • 12 In most cases, the permanent tooth
develops normally, although the time and direction of erup-
tion are influenced by the persistent deciduous tooth. Per-
manent incisors erupt at a site immediately caudal to the
persistent deciduous incisors. Persistent deciduous canine
teeth cause a lingual deviation of the erupting mandibular
canine teeth and a facial deviation of the maxillary canine
teeth. Furthennore, persistent deciduous teeth a lter the gin-
gival contour, with plaque and debris accumulating be-
tween the deciduous and permanent teeth. u. 27
Embedded and Impacted Teeth
Embedded teeth are individual teeth that are unerupted,
usually because of a lack of eruptive force. 104 Individual,
e mbedded canine teeth are occasionally seen in the dog
and are usually of traumatic origin. Multiple embedded
teeth are a possible sequel to distemper. 10· 62 An impacted
tooth is prevented from erupting by some mechanical bar-
rier in the eruption path.94· 104 A dentigerous cyst may
develop around the crown of the impacted tooth.J1. 79. 104
Partially embedded or impacted teeth that communicate
with the oral cavity may develop pcriodontitis. 104
Abnormal Structure
Enamel Hypoplasia
Enamel hypoplasia is the incomplete or defective forma-
tion of organic enamel matrix of tecth.'04 Hereditary and
2640 Demtstry
environmental forms occur in humans, IO<I but to date, only
the environmental fonn occurs in dogs. Enamel hypoplasia
results from damage to the ameloblasts while the teeth are
dcvcloping. 20• This damage can be caused by a variety of
infectious and noninfectious conditions. 10<1 Epitheliotropic
virus infect ions, particularly morbilli viruses such as dis-
temper, arc the most important causes.5• 25• 62• 6S
Mild enamel hypoplasia is characterized by irregular
enamel, the areas of which initially appear opaque but soon
become tained brown. SmaJI irregular pits may be present.
In the more severe form, a band-shaped absence or ex-
treme thinning of the enamel is visible (Fig. 195-2).20• 27·62
The location or the lesions on the tooth is related to the
developmental stage in which the ameloblasts were dam-
12 Teeth with enamel hypoplasia are predisposed
to staining and calculus accumulation because of the rough
21
Enamel hypoplasia affects Lhe entire dentition as a result
of distemper and other systemic causes. Ambjerg5 noted a
high incidence of generalized root hypoplasia with dis-
temper-induced enamel hypoplasia. Trauma to the develop-
ing dental follicles may result in enamel hypoplasia or one
or more teeth.
Enamel hypoplasia occurring in the dog and resulting
from excessive nuoride intake during tooth formation has
been recorded. 4H· 72 The pathophysiological factors are simi-
lar to those of distemper enamel hypoplasia. Damage to
ameloblasts occurs, but interference with the calcification
process of the matrix may also take place. 10<1
Odontogenesis lmperfecta
Odontogencsic; imperfecta, or odontodysplasia, is rare in
humans and dogs.' 111 · 11).1 The shape of an affected tooth is
markedly altered and irregular, often with radiological evi-
dence of defective mineralization. One or several teeth in a
localized area may be affected. The etiology is uncertain,
although trauma and osteomyelitis have been implicated.K 1
Generalized odontodysplasia was found in two young dogs
with severe renal diseasc. 23
Tetracycline Staining
Tetracyc line administered during tooth development is
incorporated in the enamel and dentin and causes a perma-
Figure 195-2. Enamel hypoplas•a
m the dog. A. Mild fonn showing
opaque and stained areas as well as
irregular pits. B. More M:vere fonn
charncterized by a band-shaped absence
of enamel.
nent brown-yellow-orange discoloration. 9 • 27 The dental
structure is otherwise normal. This drug is not given to
dogs and cats before the age of 5 montlts or to pregnant
female animals. Treatment of this condition by bleaching
has been used on an experimental and limited clinical basis
in the dog.12s. 12'1. n6. m
INJURIES TO TEETH
Attrition and Abrasion
Attrition
Anrition is Lhe wearing away of dental substance due to
occlusal contact and mastication. Attrition is usually a nor-
mal and physiological process associated with aging. 105 At-
trition may be abnormal and enhanced because of maloc-
clusion, with one or more teeth wearing abnonnally against
othcrs.94 This abnormality is initially manifested by wear
facets, a common finding in dogs.46 As wear continues,
dentin is exposed, aJld sclerosis of the exposed dentinal
tubules takes place. The rougher surface of the dentin
stains easily, with the slightly yellowish dentin contrasting
with the surrounding white enamel. As attrition proceeds, a
brown spot may become visible in the center of the occlu-
sal table because of the exposure of tertiary dentin. Loss of
dental substance by attrition is usually minimal in carni-
vores with a normal diet.27. '14
Abrasion
Abrasion refers to the pathological wearing away of den-
tal substance through an abnormaJ mechanical process. 105
Abnonnal chewing habits. such as biting stones. pathologi-
cal gnawing, and cage biting, are common causes of abm-
sion.'14 Chewing on metal cage results in typical le-
sions characterized by a considerable loss of dental
substance on the distal aspect of the teeth, particularly the
maxillary canine teeth and third incisors.27 Tmces of metal
can be ecn on the affected dental surfaces (Fig. 195-3).
This condition predisposes the animal to fractures of the
affected tccth. 27• 69 Pulp exposure may occur if the rate of
formation of tertiary dentin cannot keep pace with the
abrasion.'14

Figure 195-3. Abra.\ion of the dbtal aspect of the
tncisor and cantne tooth due to cage baung tn a dog.
Dental Fractures
Types
Dental fractures are common in dogs and cats, with an
incidence of 14% in the cat and 27% in the dog. 46• 96
Fahrenkrug30 reported a higher incidence in young dogs. In
the cat, fractures mainly involve the canine teeth.96 Re-
ported figures regarding the location of dental fractures in
the dog differY· 46. 69 Oblique fractures on the mesial as-
pect of canine teeth arc common in working dogs. 69 The
World Health Organization classification of dental fractures
in humansl has been modified for use in dogs and cats
(Table 195-1 and Fig. 195-4),1 19
Pathophysiology
Enamel fractures and most uncomplicated crown frac-
tures are of little clinical importance in small animals.
Dogs are largely resistant to caries. The exposed dentin is
initially sensitive, and this sensitivity disappears because of
Table 195-1. Classification of Dental Fractures,
Category
Enamel infraction or fracture
Uncomplicated crown fracture
Complicated crown fracture
Uncomplicated crown-root fracture
Complicated crown-root fracture
Root fracture
Oral Pathology 2641
sclerosis of the dentinal tubules and formation of tertiary
dentin in the pulp chamber.l 14 Pulpitis may occur if the
fracture exposes the wide dentinal tubules near the pulp.l 14
Dentin is rougher than enamel and facilitates plaque and
calculus accumulation. Sharp fracture edges may cause soft
tissue trauma and can be rounded off if
Crown-root fractures involve the periodontal ligament
and may lead to periodontitis because of the altered gingi-
val contour. A small fracture fragment and the overlying
unsupported gingiva can be removed to restore physiologi-
cal contour. Many deep crown-root fractures lead to irre-
versible periodontitis and indicate extraction. Complicated
crown fractures cause pulp exposure and ensuing endodon-
tic disease. 27· 94
Root fractures can be traumatic or iatrogenic in origin. A
root tip left behind may become covered by bone and
gingiva in the absence of infection.89 Altematively, pulp
necrosis may take place and lead to sequestration. An ex-
isting periapical granuloma does not resolve in the pres-
ence of a retained root fragment. Pathological root fractures
are common in the cat because of odontoclastic resorption
lesions.92. t2t
thtrd
Other Injuries to Dental Tissues
Injuries to periodontal tissues arc rarely diagnosed, with
the exception of lateral luxation, extrusive luxation, and
exarticulation. Lateral luxation is charactenzcd by displace-
ment of the tooth and comminution or fracture of the
alveolar socket.3 Extrusive luxation and cxarticulation arc
the partial and complete displacement of the tooth from its
socket, respectively. 3 Immediate repositioning or reimplan-
tation of the tooth, followed by splinting, is indicated.47 No
data are available on the success rate in animals, but in
humans, the rate of long-term failure due to root resorption
is high.l
Response to Trauma
Dentin-Pulp Complex
Secondary dentin is formed by the odontoblasts after
°
root formation has been complctcd. 11 Continuous deposi-
tion of dentin results in a progressive reduction in size of
the pulp chamber. The formation of secondary dentin oc-
Definition
A chip fracture or crack of the enamel only
A fracture involving enamel and denun.
but not exposing the pulp
A fracture mvolving enamel and denim and
exposing the pulp
A fracture involving enamel, dentin, and
cementum. but not eltposing the pulp
A fracture tnvolving enamel, dentin. and
cementum and eltposing the pulp
A fracture involving dentin, cementum, and
the pulp
2642 Dentistry

Figure 195-4. Classification of dental fractures. A.

Enamel fracture. B, Uncomplicated crown fracture. C.
Complicated crown fracture. D. Uncomplicated crown·
root fracture. E. Complicated crown-root fracture. F.
Root fracture.

curs as a response of the tooth to stimuli of the normal Resorption

aging process. Tertiary dentin (also referred to as irregular
secondary dentin or reparative dentin) results from the irri- Internal resorption is poorly understood and may accom-
tation of odontoblastic processes within the dentinal tu- pany endodontic disease. It is characterized by resorption
bules.tos. tto. tt 4 Tertiary dentin is produced by the odonto- of the pulpal surface of the dentin and by filling of the
blasts that are directly affected by the irritation. Irritation dental defect with vascular pulp tissue. 104 If resorption oc-
of the odontoblastic processes may occur in a variety of curs in the crown, discoloration and enamel perforation
conditions during which dentin is exposed. may take place.94 Internal resorption is an indication for
In attrition, abrasion, and uncomplicated dental fTactures, endodontic treatment.
the formation of tertiary dentin usually seals off the pulp External resorption refers to resorption that begins on the
cavity effectively. With progressive wear, the tertiary den- root surface. The role of osteoclasts in this condition is
tin may become evident as a brown spot in the center of unclear. 104 External resorption may be associated with peri-
the occlusal surface. This condition can be differentiated apical disease, periodontal trauma (including reimplantation
from an exposed pulp chamber with a dental explorer. The of exarticulated teeth), tumors, cysts, and excessive ortho-
brown color results from the irregular tertiary dentin, which dontic forces. Idiopathic root resorption in the dog is un-
stains easily. With severe abrasion, pulp may be exposed if common but is occasionally seen in geriatric patients, and
tertiary den'lin formation cannot keep pace with rapid wear. its pathogenesis is unclear. 6
Severe irritation of the odontoblastic process may lead to
pulp necrosis, even without direct pulp exposure. This
tation may occur in active carious lesions or when irritating
restorative materials are applied directly onto dentin. tt4
Exposed dentin is painful because of the presence of
intradental nerve fibers and ftuid movement through the
tubules. 55· tto. tt 4 Pain is manifested by sensitivity to heat,
cold, and pressure; it eventually disappears as the calcifica-
tion of the primary dentinal tubules is followed by sclero-
sis.tos
On occasion, the integrity of the hard tissues of the tooth
is nor distorted, but hemorrhage occurs in the root canal,
with subsequent pulpal necrosis. This process may be dem-
onstrated by discoloration of the crown and is an indication
for endodontic treatment. 94
Complicated dental fractures imply exposure of the pulp
cavity. The initial inftammatory response is evidenced by
hemorrhage and signs of acute pain. This stage may be
followed by transient superficial pulpal hyperplasia, known
as pulp polyp in humans (Fig. 195-5).3 Invariably, migra- Figure 195-5. Recent complicated crown-root fracture of a mandibu-
tion of bacteria into the pulp occurs rapidly, ultimately lar canine tooth in a dog, with ev idence of superficial pulpal hyperplasia
leading to pulpal necrosis.ss. tos. t3t ("pulp polyp") (arrow).

Feline Odontoclastic Resorption
Lesions
Feline odontoclastic resorption lesions are common. The
external lesions mainly occur at or below the cementoena-
mel junction, usually on the buccal aspect, on the mesial
and distal edges, or at the furcation; lesions may also
develop farther apically on the periodontal ligament. They
are often found with periodontal disease, but the associa-
tion is unclear. 74• 92• <n In most studies, the most commonly
affected teeth were the mandibular third premolar and first
molar and the maxillary fourth premolar, although all teeth
can be affected.s7 • 11 7 Feline odontoclastic resorption lesions
are a recent phenomenon; few lesions are found in skull
collections datirng before 1950. The current incidence in
cats presented for veterinary or dental care can be as high
as 67%. 117 The prevalence and number of affected teeth
increase with increasing age.s 7 Feline odontoclastic resorp-
tion lesions may affect the root without any external evi-
dence of lesions; this occurs most commonly in the canine
teeth and may lead to disruption of all organized root
structure.
The exact pathogenesis of feline odontoclastic resorption
lesions is undetermined, but they are not carious le-
sions.84· 86· 99 Tlhe etiology of odontoclastic resorption le-
sions is unclear. A local immune response and the release
of biochemical components (e.g., cytokines) that attract
odontoclasts offer a plausible explanation.86 • 106 An abnor-
mal local and systemic calcium metabolism (e.g., a cal-
cium-poor diet) may also play a role. Other dietary factors
have not yet been identified, except one study showed that
the acidic coating of dry cat food did not predispose the
teeth to their development. 139 A study found an association
between feline odontoclastic resorption lesions and low
magnesium, calcium, phosphorus, and potassium dietary
content.76
Figure 195- 6 . A, Feline odontoclastic resorption lesion affecting the mandibular third premolar in a cat; the lesion is covered by hyperplastic gingival
tissue (arrow). 8 , Carious lesion or the occlusal surface or a maxillary first molar in a dog.
Oral Pathology 2643
Two stages are identifiable histopathologically in the
pathogenesis: an acute stage, with many odontoclasts on
the surface of the excavated lacunae; and a reparative
stage, with few odontoclasts on the dentinal surface and
the deposition of bonelike or cementum-like material in the
defects. 86
External and internal odontoclastic resorption lesions can
be difficult to evaluate, both clinically and radiologically.
Externally, lesions may be seen as the localized absence of
dental substance (Fig. 195-6A). The lesions are usually
filled with granulation tissue. The severity of the concomi-
tant gingivitis is variable. Lesions can be diagnosed with
use of a dental explorer. The lesions arc usually painful,
and even under anesthesia, jaw chattering often occurs
when extemal feline odontoclastic resorption lesions are
probed. Clinical examination alone tends to underestimate
the incidence and severity of feline odontoclastic resorption
lesions compared with radiographic examination. 121 Survey
radiographs are indicated if there is any clinical suspicion
of feline odontoclastic resorption lesions. Lesions are visi-
ble as sharply defined radiolucent areas, externally most
often at the cementoenamel junction, and internally around
the root canal or pulp chamber. 121 The extent of feline
odontoclastic resorption lesions varies from superficial to
deep; pulp involvement may occur with deep lesions, al-
though periapical lesions are rare. 73
CARIES
Caries, a microbial disease of the calcified tissues of the
tooth, is characterized by demineralization of the inorganic
portion and destruction of the organic substance of the
tooth. 103 The etiology is complex, and no consensus is
found regarding the relative importance of acid-producing
bacteria or proteolytic bacteria and the role of chelation. 103
2644 Dentistry
The prevalance of caries in the dog varies from 0.5% to
35%8. 32. M. so. sz; however, most authors agree that the
prevalance is low. 27 • 46• 65 • 82• 94• 98 A study revealed that
5.3% of dogs presented to a veterinary dental referral prac-
tice had carics.50 A possible explanation for the discrepan-
cies in the reported prevalence rates of caries in the dog is
that most authors fail to define criteria for diagnosing car-
ies.32 Data on the prevalence of caries in the cat are un-
available (feline odontoclastic resorption does not fulfill the
criteria for caries).84• 92• 97 • 100
Caries in the dog may occur as pit or fissure caries
(class I cavities) on the occlusal surface or as smooth-
swface caries (class V cavities) around the tooth neck.29. so. 98
Fissure caries are the most common and usually affect the
maxillary and mandibular first molars (Fig. I95-6B).a· 511• &n
Cervical caries are differentiated from external resorption
as previously described. Carious lesions have been classi-
tied as superficial, intennediate, or deep, depending on in-
volvement of enamel only, enamel and dentin, or enamel.
dentin, and pulp, respectively.65 An early carious lesion
usually appears brown or black and feels slightly soft or
sticky when probed with a fine dental explorer. 103 A cari-
ous cavity involving the dentin is filled with disintegrated
dental substance and debris. The walls of the cavity are
lined with contaminated decalcified dentin, in contrast with
resorption defects, which are lined by heallhy, hard dental
substance. 103
Clinical signs associated with intennediate carious le-
sions are difficulty in eating and jaw chattering,94 which
can be attributed to the irritation of intradental nerve fibers
and odontoblastic processes in the dentinal tubules. 55 • 1111
Pulpitis may ensue; it is invariably present with deep cari-
ous
Reasons for low prevalence of caries in the dog have
been proposed. 32• 65 The morphology of the teeth is not
conducive to caries. The conical shape and the absence of
deep, narrow occlusal fissures and pits promote natural
cleaning. The only teeth with large occlusal surfaces are
the first molars, which are most commonly affected by
caries. The salivary pH and urea concentration are higher
in dogs than in humans, and these factors cause neutraliza-
tion of acids formed by bacteria.32 Streptococcus mutans
and Lactobacillus species have been isolated, rarely, from
the mouths of normal dogs and from dogs with periodontal
disease. 19• 95 Experimental attempts to induce carious le-
sions in the dog have proved difficult.71
ODONTOGENIC TUMORS AND
CYSTS
Odontogenic tumors are rare in all spccies.35• 90 Precise
epidemiological data are not available for the dog and cat.
One of the main reasons for this is the continuing confu-
sion about the true nature of some of these lesions. In
many surveys, the so-called epulides, localized swellings
on the gingival margin that constitute a variety of patho-
logical entities, are either grouped together or excluded.
Recent findings indicate that many epulides are odonto-
genic tumors. Another reason is that many clinicians do
not routinely submit epulides for histopathological exami-
nation, thereby introducing bias in the studies based on
archival material. m An accurate assessment of the nature
of the condition is a prerequisite for therapeutic decision-
making. It is therefore important to understand the biology
of odontugenic tumors.
Odontogenic cysts are rare lesions, and a variety of
types have been described.M, wz The dentigerous (or follic-
ular) cyst is the most common in animals. 36 This is a cyst
that encloses the crown and is attached to the neck of an
unerupted tooth.M In the dog, the mandibular first premolar
and the canine teeth are most commonly involved.·11 • 7 9,
120 The clinical importance of a dentigerous cyst is that it
is an expansile lesion, which may deform and weaken the
jaw. Malignant transformation of the cyst wall is rare but
occurs in humans and in dogs.90• IO'Z
Classifications
Odontogenic tumors have traditionally been classified by
the presence or absence of induction. 35 • 1111• 127 To under-
stand the classification based on induction, it is important
to consider the reciprocal interactions of epithelial and
mesenchymal tissues during odontogenesis. 110 The epithe-
lial dental lamina invaginates to form the dental organ. The
inner dental organ epithelium consists of the pre-ameloblasts.
The mesenchymal odontoblast precursors migrate to the
basement membrane and eventually make contact with the
pre-ameloblasts. The pre-ameloblasts then induce the odon-
toblasts to form the dentin. In tum, the odontoblasts influ-
ence the ameloblasts, and these cells start secreting the
enamel matrix. The mesenchymal stroma enclosed in the
developing dental follicle is induced to take on the charac-
teristics of dental pulp. As tooth formation is completed,
the odontogenic epithelium disappears, leaving behind the
epithelial cell rests of Malassez in the periodontal ligament
and the cell rests of Serres in the gingiva. These clusters of
epithelial cells retain their odontogenic potential, which
may subsequently be expressed in neoplasia.
The ameloblastoma is an example of a noninductive tu-
mor. In this tumor type, the neoplastic cells of ameloblast
origin do not induce the surrounding mesenchymal cells.
Therefore, no dental hard tissues are fonned, and the tumor
remains essentially a soft tissue tumor. The odontoma is
the best example of an inductive tumor. Odontomas are
tumors of odontogenic epithelium with induction of odon-
togenic ectomesenchyme characterized by the fonnation of
all dental hard and soft tissues, including enamel, dentin, ,......
cementum, and pulp. Although the classification based on
induction has been abandoned, there is merit in lhis classi-
fication because the underlying processes help to explain
the clinicopathological correlations.
The World Health Organization has adopted a classifica-
tion based on the epithelial, mesenchymal. or mixed epithe-
lial-mesenchymal origin of the neoplastic cells, rather than
one based on inductive changes.64 Table 195-2 summa-
rizes the currently accepted classification of human odonto-
genic tumors, with one cx.ample of each type known to
occur in animals (Table 195-2).
 Table 195-2. Tumors Related to the Odontogenic Apparatus

Be n ign M cdignant

Odontogenic.: epithelium Odontogenic epithelium with Odontogenic cctomcsenchyme Odontogenit: carcinomas Odontogenic sarcomas Odontogenic carcinosarcoma
without odontogenic odontogenic with or without included
ectomesenchyme ectomcscnchymc, with or odontogeni<: epilhelium
without demal hard
formation
Example
Ameloblastoma Odontoma Odontogen ic lihn)ma Prjn)ary intraosseou s Ameloblastic
carcinoma tibrodcntinosarcoma

..
N
0<
VI
2646 Dentistry
Common Odontogenic Tumors
Ameloblastoma
The central or intraosseous ameloblastoma is one of the
most common odontogenic tumors in humans, but it is
uncommon in dogs and rare in cats.26. 39 · 42 It is occasion-
ally incorrectly referred to as adamantinoma in animals.67 • 102
This tumor usually occurs as a locally invasive neoplasm
with osteolysis around the tooth roots and cystic changes
(Fig. 195-7A).2 1• 26 • M The classic histological appearance
of an ameloblastoma is a follicular arrangement of amelo-
blasts and stellate reticulum cells, resembling the basic
structure of the dental organ. 26 • 64 • 75 A number of histologi-
cal variants occur. 64 Ameloblastoma in the dog is often
characterized by focal keratinization, and this may also
occur in the cat.26• 39• 42 Metastasis has not been described.
The canine acanthomatous ameloblastoma is a benign
odontogenic tumor with the same histological characteris-
tics as the centrally located ameloblastoma, but appearing
in the gingiva and mucosa of the tooth-bearing area of the
jaws.37• 41 This variant of ameloblastoma differs from the
peripheral ameloblastoma in humans in that it invades
bone; the term canine acanthomatous ameloblastoma was
therefore suggested to make this distinction. 37• 38 • 41 ln one
review of canine epulides, the majority of lesions, which
were originally classified as acanthomatous epulis, were
canine acanthomatous ameloblastoma. 123 These lesions are
composed of islands and sheets of mature squamous epi-
thelium within a collagenous fibrous connective tissue
stroma of low to moderate cellularity. These islands and
sheets are each bounded by a row of palisading cells with
nuclear polarization away from the basement membrane.
Infiltration in the underlying bone is evident in most cases.
The radiological picture of a canine acanthomatous amelo-
blastoma is dominated by discrete infiltration, alveolar bone
resorption, and tooth displacement. ln the dog, local recur-
rence is common after marginal excision, and wide exci-
sion is therefore recommended. 133
Peripheral Odontogenic Fibroma
A large proportion of rumors previously described as
fibromatous and ossifying epulides are peripheral odonto-
genic fibromas. 40• 123 This is a slowly growing, benign neo-
plasm characterized by the proliferation of fibrous tissue in
which isolated islands or strands of odontogenic epithelium
are present (see Fig. 195 -8A). A variety of bone, osteoid,
dentinoid, or even cementum-like material may be found,
often in close association with the odontogenic epithelium,
suggesting mesenchymal induction. 123 Radiological features
vary according to the presence and amount of mineralized
products. Peripheral odontogenic fibroma does not recur if
adequately excised. In humans, the peripheral odontogenic
fibroma is rare, whereas it is common in dogs. 38. 40
Odontoma
An odontoma is a tumor in which both the epithelial and
mesenchymal cells are well differentiated, resulting in the
Figure 195-7. Odontogenic tumors in the dog. A. Central amelo-
blastoma of lhe rostral part of lhe mandible. 8, Radiograph of a
complex odontoma of the caudal part of the body of the mandible. C.
Compound odontoma associated wilh the crown of a maxillary fourth
premolar.

fonnation of all dental tissue types. An odontoma may also
be considered a hamartoma rather than a ncoplasm.' 5· 88
The dental tissues may or may not exhibit a nonnal rela-
tion to one another. 102 An odontoma in which toothlike
structures arc present indicates advanced cellular differenti-
ation and is referred to as a compound odontoma. An
odontoma in which the conglomerate of dental tissues
bears no resemblance to a tooth is called a complex odon-
toma.M 88 102 Odontomas have been diagnosed in young
dogs and cats. 127 The radiological appearance is typical and
is either a sharply defined mass of calcified material sur-
rounded by a narrow radiolucent band or a variable num-
ber of toothlike structures. An odontoma may be associated
with an unerupted tooth or a dentigerous cyst, or it may be
attached to an otherwise normal tooth (Fig. 195-7C).60
The tenn ameloblastic odontoma is occasionally encoun-
tered in the veterinary literature.83 An ameloblastic odon-
toma is an ameloblastoma with focal differentiation into an
odontoma. "\.I
Feline Inductive Odontog enic Tumor
This tumor type was originally described in young cats
as inductive fibroameloblastoma.22• 109 This tumor is charac-
terited by ameloblastic epithelial cells arranged around
dental pulplike stroma.43 The rostral maxilla is the most
common site of occurrence. The tumor may be locally
invasive, but metastasis has not been recorded.
Oral Pathology 2647
Figure 195-8. A wide variety of tumors may appear clinically as
epulides in the dog. A, Peripheral odontogenic fibroma. 8 , Canine
ucanthomatous ameloblastoma (acanthomatous epul is). C, Squamous
cell carcinoma (a) and focal fibrous hypcrpla,ia (b) in the same oral
c avity. illustrating the need for multiple biopsies.
Amyloid-Producing Odontogenic
Tumor
This tumor is rare in dogs and cats and may also occur
clinically as an epulis. It has previously been referred to as a
calcifying epithelial odontogenic tumor, although it is not the
counterpart of the human calcifying epithelial odontogenic tu-
mor.18· 44 • 87 The tenn amyloid-producing odontogenic tumor
is more appropriate. The tumor bears some resemblance to an
ameloblastoma: the epithelium in some areas exhibits palisad-
ing of the basal cells, and stellate reticulum may occur focally.
The most prominent feature is the presence of amyloid, which
calcifies. The tumor may recur after excision, but metastasis
does not occur. 1• 44• 59• 85 • 90, 123
..Epulides"
The tc nn epulis is derived from the Greek epi-oulon.
meaning "on the gum." It is a descriptive clinical tem1
applied to a variety of neoplastic and non-neoplastic tu-
mors that appear on the gingiva as circumscribed elevated
lesions. The nature of these lesions should be determined
histologically (Fig. 195 - 8).
The epulis has been described as the most common
benign oral tumor in the dog. ln other reports, this tumor is
not even mentioned, making it difficult to compare relative
2648 Dentisrry
incidence/'7 • m, 12c' This discrepancy can be attributed to
continuing confusion about the origin and nomenclature of
the epulis. Dubielzig and coworkers24 recognized three
types, namely, fibromatous, ossifying, and acanthomatous.
The common origin of these tumors was hypothesized to
be the periodontal ligament. In a later publication, Dubiel-
zig and Thrall26 dearly differentiate between the acanthom-
atous epulis and the ameloblastoma. A number of authors
subsequently challenged the Dubielzig classification. Bos-
tock and White14 questioned the common origin of these
tumors. These authors recognize the ameloblastoma but re-
classify the fibromatous and ossifying epulides as periph-
eral odontogenic fibromas and the acanthumatous epulis as
a basal cell carcinoma. Conversely, Reichart and
found inflammatory fibrous hyperplasia with and without
metaplastic bone formation and plexiform epithelial hyper-
plasia, and they regarded the acanthomatous epulis as an
ameloblastoma.
More recently, the classifications and well-described his-
tological criteria for similar tumors in humans were used in
classifying a large series of cpulidcs.37· 38· 40• 4 1. 123 It was
found that the majority of epulides could be classified as
focal fibrous hyperplasia. This non-neoplastic localized gin-
gival hyperplasia coincides with fibrous epulis:'9 Chronic
gingivitis may lead to nodular proliferation and granulation
tissue. These lesions may be associated with underlying
periodontal disease. 21 Pyogenic granuloma and peripheral
giant cell granuloma may also clinically present as an epu-
lis.101· 116 The rest of the lesions that were previously diag-
nosed as fibromatous and ossifying epulides were reclassi-
fied as peripheral odontogenic fibroma (World Health
Organization type) (Fig. 195-SA), in agreement with cur-
rent criteria in human oral :n. 411 Most so-called
acanthomatous epulides were canine acanthomatous amelo-
blastoma (Fig. 195-8H)Y· 41 · m This type of ameloblas-
toma is a tumor believed co originate either in the connec-
tive tissue of the gingiva from remnants of the dental
lamina (rests of Serres) or from the basal cell layer of the
oral mucosa.e3 The canine acanthomatous ameloblastoma
should not be confused with the central ameloblastoma,
which is a well-recognized entity that is distinct from the
acanthomatous epulis. 24• 1 6
Epulides in cats are rare and may include peripheral
odontogenic fibroma, amyloid-producing odontogenic tu-
mor, and focal fibrous hyperplasia.l 7. 21. 44, 109
Other Related Soft Tissue
Lesions
Generalized gingival hyperplasia is occasionally seen in
the boxer and collie and is a poorly understood condi-
tion.16· 21 Treatment consists of excision of the hyperplastic
tissue and gingivoplasty, combined with appropriate peri-
odontal treatment. Gingival hyperplasia occurs in dogs and
cats after experimental administration of phenytoin and cy-
closporine, although clinical cases are rare. 51 · 54 · 130
A common, non-neoplastic, proliferative, oral lesion in
the dog is traumatic hyperplasia of sublingual or buccal
oral mucosa, also referred to as gum-chewer syndrome.52
These are self-inflicted traumatic lesions resulting in hyper-
plasia and fibrosis of either the loose, sublingual oral mu-
cosa or the buccal mucosa adjacent in the caudal part of
the oral cavity. These lesions typically occur in small-breed
dogs. Treatment is indicated if there is so much redundant
tissue that further masticatory trauma is unavoidable and
consists of excision of this tissue, followed by primary
closure.
Diagnosis and Clinical Staging
The principles of clinical staging and diagnosis of oro-
pharyngeal tumors are well established and apply also to
epulides and odontogenic tumors. 134 Because epulides may
be a variety of pathological entities, the diagnosis and
therapeutic plan arc not based on ·gross appearance. 311• 123
A biopsy specimen submitted for histopathological exami-
nation by a pathologist experienced in oral pathology is
essential. An incisional biopsy, by a biopsy punch, is gen-
erally the technique of choice. In selected cases of very
small tumors on the gingival margin, an excisional biopsy
by means of gingivectomy may be indicated when the
tumor can easily be excised in tow. If more than one
tumor is present, multiple biopsy specimens must be ob-
tained (Fig. 195-SC).
Treatment
The therapeutic plan is based on the clinical and radio-
graphic findings and the histopathological examination
(Fig. 195-9).56
Surgical excisions can be classified according to the
width of the surgical margins.45 It is impot1ant to choose
the appropriate type of excision. Surrounding the tumor are
a pseudocapsule and a reactive zone; the pscudocapsule is
a macroscopically visible membrane consisting of nonnal
and neoplastic cells: the reactive zone consists mainly of
inflammatory cells. An intracapsular excision involves re-
moval of the tumor from within its pseudocapsule or the
piecemeal removal of neoplastic tissue. This is rarely indi-
cated but may be acceptable for an odontoma that can be
curetted out of the jaw bone.nn. KH A marginal excision
involves a dissection plane located in the reactive zone
around the tumor and its pseudocapsule. This excision is
indicated for well-differentiated, benign tumor types. Most
of the odontogenic tumors fall into this category; the pe-
ripheral odontogenic fibroma is a good example, although
regrowth after marginal excision may occur. 14 Non-
neoplastic growths, such as focal fibrous hyperplasia, can
also be excised in this manner. In doing so, one should
strive for a physiological gingival contour (gingivoplasty)
and treat the associated periodontal disease. However, mar-
ginal excision is not indicated for malignant or infiltrating
tumor types; not all the neoplastic tissue can be removed,
and this almost invariably results in locaJ tumor regrowth.
These tumor types require at least wide excision. This
involves the en bloc removal of the tumor, the pseudocap-
sule, the reactive zone, and a wide margin of normal tis-
sue. This is achieved by performing maxlllectomy or man-
dibulectomy. This is the treatment of choice for canine
acanthomatous ameloblastoma. 133 Specimens are submitted

Non-neoplastic lesion
(e.g.• focal fibrous
hyperplasia)
Most odontogenic tumors
(e.g., peripheral
odontogenic fibroma)
Marginal excision lntracapsular or
(gingivectomy) marginal excision
Figure 195-9. Treatment of epulides and suspected odontogenic twnors.
for histopathological examination of the surgical wound
edges to confirm complete removal.
Radiation therapy of canine acanthomatous ameloblas-
toma in the dog is well documented, and good results have
been reported.67 • ('8 · 111 However, malignant tumor formation
at the sites of previously irradiated lesions has also been
recorded. 112• 135 Osteoradionecrosis is a serious compJica-
tion.'12
References
I. Abbott DP. et al: Calcifying epithelial odontogenic tumours in three
cats and a dog. J Comp Pathol96:131, 1986.
2. Aitchison J: Incisor dentitions of short·muz:zled dogs. Vet Ret: 76:
165, 1964.
3. Andreasen JO. Andreasen FM: Textbook and Color Atlas of Trau·
malic Injuries lO the Teeth, 3rd ed. Munksgaan:I, Copenhagen, 1994.
4. Arnall L: Some asp«ts of dental development in the dog. IU. Some
common variations in the dentitions . .I Small Anim Pracr 2:195,
1962.
5. Arnbjcrg J: Schmelz· aitd Wurz:elbypoplasien nach Staupe [Tooth
enamel and root hypoplasia following distemper in dogs]. Kleimier·
praxis J/:323. 1986.
6. Arnbjerg J: Idiopathic dental root replacement resorption in old
dogs. J Vet Dem 13:97. 1996.
7. Ambjerg J, Reibel J: Dentinogenesis impe1fecta bei zwei Hunden
[Dentinogenesis imperfecta in two dogs]. Kleintierpraxis 33:463,
1988.
8. Bell AF: Dental in the dog . .I Small Anim Pract 6:421. 1965.
9. Bennett IC, Law DB: Incorporation of tetracycline in developing
enamel and dentin in dogs. J Dent Child 34:93, 1967.
I 0. Bodingbauer J; Retention of teeth in dogs as a sequel to distemper
infection. Vet Rec 72:636, 1960.
11. Bodingbauer J: Oligodontia and polyodontia in prehistoric dugs. Vet
Rec 75:668, 1963.
12. Bodingbauer J: Korrelation zwischen Oligodontic und Milchzahnper-
sistenz als Fchlcrqucllc bei der Beurteilung des Hundegebisses [Re·
between oligodontia and persistence of the milk teeth as a
source of error in diagnosing dentition anomalies in lhe dog]. Klein·
tierpraxis 21: 12, 1976.
Oral Pathology 2649
Canine Malignant
acanthomatous odontogenic
ameloblastoma tumor
13. Bodingbauer J: Milchzahnpersistenz heim Hund. Atiologic-Folgcn·
Extraktion [Retained deciduous teeth in the dog: Aetiology, conse-
quences and extraction]. Kleintierpraxis 23:339, 197&.
14. Bostock DE, White RAS: Classification and behaviour after surgery
of canine "epulides." J Comp Pathol 97:197, 1987.
15. Buchner A, cr a1: Peripheral odontogenic fibroma. Oral Surg Oral
ME'd Oral Pathol 64:432, 1987.
16. Burstone MS, et al: Familial gingival hypertrophy in the dog (boxer
breed). Arch Pathol 54:208, 1952.
17. Colgin LM, er al: Mulliple epulides in l3 cats. Ver Parhol 38:227,
2()(11.
Ill. Colyer P: Variutiom atui Diseases the Teeth of Animals. J. Bale,
Sons & Danielsson, London, 1936.
19. Dent VE, Marsh PO: Evidence for a basic microbial commu-
nity on the tooth surface in animals. An·h Oral Bioi 26:171, 198 I.
20. Dubielz.ig RR: The effect of canine distemper viru!l on the amelo·
blastic layer of the developing tooth. Vet Pathol /6:26S, 1979.
21. Dubiel.z:ig RR: Proliferative dental and gingival diseases of dogs and
cats. JAm Anim Hosp Assoc 18:517, 19!12.
22. Dubieb:ig RR, et al: Inductive fihroameloblastoma, an unusual dental
tumor of young cats. JAm Vet Med As.wJt: /74:720, 1979.
23. Dubielz:ig RR, et al: Dental dysplasia in two young uremic Vet
Parhol 23:333, 1986.
24. Dubielz:ig RR, et al: The nomenclature of periodontal epulides in
dogs. Vet Patho/16:209, 1979.
25. Dubiclzig RR, et al: Lesions of the enamel organ of developing dog
teeth following experimental inoculation of gnotobiotic puppies with
canine distemper virus. Ver Pathol 18:684, 19SI.
26. Dubieb:ig RR, Thr41l DE: and keratinizing amelo-
blastoma in dogs. Vet Puthol /9:596, 19!!2.
27. Eisenmenger E, Zetner K: Tierafztliche Zuhnfleilkwu/e. Verlag Paul
Berlin, 1982.
28. Emily P: [mraoral radiology. Vet Clin North Am Small Anim Pruct
/6:801. 1986.
29. Emily P: Restorative dentistry. Vet Clin North .-\m Small Anim Prua
16:1195, 19!!6.
30. Fahrenkrug P: Handbuch der Zahnbehandhmg in der Kleintier·
praxis, 4th cd. A. Albrecht GmbH, Aulendorf, Germany, 1988.
31. Field EA. et al: The removal of an impacted maxillary canine and
associated dentigerous cyst in a Chow: A case report. .I Small Anim
Pract 23:159, 1982.
32. Gardner AF. et al: Dental caries in domesticated dogs. .I Am Vet
Med Assoc 140:433. 1962.
Z650 Dentistry

33. Garuner DG: The peripheral odontogenic fibroma: An attempt at ringen bij de bond [Caries, enamel hypoplasia, and dental discolour·
clarilicatkm. Oral Surg Oral Med Oral Patlto/54:40, 19!12. ation in dogs]. Tijdschr Dierf1eneeskd 107:451, 1982.
34. Gardner DG: Ameloblastic fibro-odontomas in animals llcrtcr; com- 66. Kuiper JD. et al: Polyodontie afwijkemle tandvormen bij de hond
ment!. J Oral Pathol Med 20:516, 1991. [Polyodontia and abnormal forms of teeth in dogs]. Tijdschr Dierge-
35. Gardner DG: An orderly approach to the study of neeskd 107:451, 1982.
rumours in animals. J Comp Patho/107:421, 1992. 67. Langham RF. et al: Oral in dogs. J Am Vet Med
36. Gardner DG: Dentigerous cysts in animals. Oral Surf: Oral MuJ Assm.· /46:474. 1965.
Oral Pathol 75:34!1, 1993. 6!!. Langham RF. et a\: X-ray therapy of selected odontogenic neo-
37. Gardner DG: Canine acanthomatous epulis. The only common spon- plasms in t.he dog. JAm Vet Med Assoc 170:820, 1977.
taneous amelobla.,toma in animals. Oral Surfl Oral Med Oral Pathoi 69. Le Brech C, et al: Epidemiological study nf canine teeth in
Oral Radio[ Endod 79:612, 1995. military dogs. .I Vt'l De11t /4:51, 1997.
38. Gardner DG: Epulides in the dog: A review. J Oral Pathol Med 25: 70. Levitas TC: Gemination, fusion, twinning and concrescence. J Dent
32, 1996. Cltild 32:93, 1965.
:39. Gardner DG: Ameloblastoma.' in cats: A critical evaluation of the 71. Lewis TM: Resistance of dogs to dental caries: A two-year study. J
literature and the addition of one example. J Oral Parhol Med 27: Vent Res 44:1354, 1965.
39, 1998. 72. Loeffler K, et al: Flnorose heim Hnnti [Fluorosis in ..togs]. Kl,•illtil'l'·
40. Gardner DG, Baker DC: Fibromatous epulis in dogs and peripheral praxis 24:167, 1979.
odontogenic fibroma in human beings: Two equivalent lesions. Oral 73. Lommer MJ, Verstraete FJ: Prevalence of odontoclastie resorption
Surg Oral Me.d Oral Pathol 71::317, 1991. lesions and periapical r.adiographic ·lucencies in cats: 265 cases
41. Gardner DG. Baker DC: The relationship of the canine acanthoma- (1995-199X) . .I Am Vet Med t1.mn· 2/7:1M66. 2Cl00.
tous epulis to ameloblastoma. J Comp Patho/ 108:41, 1993. 74. Lommcr MJ, Verstraete FJ: Radiographic patterns of periodontitis in
42. Gardner DG, Dubiclzig RR: The histopathological features of canine cats: 147 cases (1998-1999). JAm Vet Med Assoc 218:230, 2001.
keratinizing ameloblastoma. J Comp Pathol109:423, 1993. 75. RB: Pathology of Tumours of the Om/ Tissues. 4th ed.
43. Gardner DG, Dubiel:tig RR: Fdine inductive odontogenic tumor Churchill Livingstone, New York, 19!!4.
(inductive fibroameloblastoma)-a tumor unique In cats. J Oral 76. Lund EM, et al: Prevalence and risk for odontoclastic L'Csorp·
Pathol Med 24:185, 1995. tive lesions in cats. J Am Vet Med Assoc 212:392. 1998.
44. Gardner DG, et al: The so-called calcifying epithelial odontogenic 77. Lups P: Gcbiss- und Zahnvaciationen an ciner Scric von 257 Haus-
tumour in and cats (amyloid-producing odomogcnic tumour). I katzen (Felis sill't'stris f cams L., 175!!) [Variation& in the dentition
Comp Pathol /1/:221, 1994. and teeth of a series of 257 domestic cats]. 'Lool Abh Mus Tierk
45. Gilson SD, Stone EA: Prindples of oncologic surgery. Dresden 34:155, 1976.
Conlin Pra<:l Vet 12:827, 1990. 78. Lups P: Vcrgleichcndc am zwciten obcren Vorbackcn-
46. Golden AL, et al: A survey of oral and dental disea.,es in zalw P2 dcr Hauskatzc Felis .f. ('tttus [Compara1ivc s1udies
at a veterinary hospital. .I Am Anim Hosp ,1.uoc /8:891_ of the second upper premolar P2 in domestic catsl. Z Saugetier·
191!2. kunde 45:245, 1980.
47. Grads M, Orsini P: Treatment of traumatic dental displacement in 79. Manfra Macrena S, ct al: An iatrogenic dentigerous cyst in a dog. .I
dogs: Sil\ cases of lateral luxation. .I Vn Dent 15:M, 1998. Vet Vent 6:11, 1989.
48. Grancher I>. et al: Fluorosc bcim Hund in dogs]. Klein- 80. Meyer R, Suter G: Epidemiological and morphological studies on
fierpraxis 33:203, 191!8. canine teeth. J. Report: Epidemiological studies [in German].
49. Greenwood AM, O'Brien FV: The fibrous epulis in the dog. J Oral Schweiz Arch Tierheilkd 1/8:307, 1976.
Patlwl4:o7, 1975. RI. Meyer R. el al: Epidemiological and morphological studies of the
50. Hale FA: Dental caries in the dog. J Vel Vent 15:79, 1991!. canine teeth. II. Morphological studies [in German]. Scltweiz Arch
51. Hassell TM, Page RC: The major metabolite of phenytoin (Dilantin) Tin·he.ilkd /22:503. 1980.
induces gingival overgrov.1h in cats. J Periodomal Re.< /3:21!0, !12. M: Zahnai'7.tlkh-vergleichende Unrersuchungen an 425 Hun-
1971!. demal examination of 425 dog skulls].
52. Hawkins BJ: Gum-chewer syndrome: Self-inflicted sublingual and Schweiz Arch Tierheilkd 100:209, 1958.
self-inflicted buccal trauma. Compend Conlin Educ Pracr Vet 14: 83. Nold JB, et al: Amcloblastic odontoma in a dog. J Am Vet Med
219. 1992. Assoc 185:996, 1984.
53. Head KW: Tumours of t.he upper alimentary tract. Bull Wm·/d 84. Ohba S, et al: A histopathological study of neck lesions in feline
Health Organ 53:145, 1976. teeth. JAm Anim Hosp Assoc 29:216, 1993.
54. Heijl L, Sundin Y: Nitrendipine-induced gingival overgrowth in 85. Olunacbi T, et al: Calcifying epithelial odontogenic tumours in small
dogs. J Periodomo/60:104, 191!9. domesticated carnivore&: Histological, inununohistochemical and
55. Hirvonen l'J, et a!: The excitability of dog plllp nerves in relation to electron microscopical studies. J Comp Parho/ 114:305. 1996.
the condition of dentine surface. J Endod 10:294, 191!4. 86. Okuda A, Harvey CE: Etiopathogenesis of feline dental resorptive
56. Hoyt RF, Withrow SJ: Oral malignancy in the dog. J Am Anim lesions. Vet Clin North Am Small Anim /'racr 22:1:385, 1992.
Hosp Assoc 20:&3, 19!14. 87. Pfister H. Meszaros J: Partial chacactcrizmion of a canine oml papil-
57. Ingham KE, et al: Prevalence of odontoclastic resorptive lesions in a lomavirus. Virology 104:243, 1980.
population of clinically healthy cals. J Small Anim Pract 42:439, 88. Philipsen HP, Reichert PA: Calcifying epithelial odontogenic rumor:
2001. .13iological profile based on 181 cases from the literature. Oral Oncol
SR. GT, Kaminski EJ: Pulpal response to bacteria in the dog_ 36:11- 2000.
Oral Surg Oral Med Orall'athol 48:353. 1979. !19. Plata RL, et al: Intentional retention of vital submerged roots in
59. Ishikawa T, Yan1amoto H: Case of calcifying epithelial Oral SUJ·g Oral Med Oral Patho/42:100, 1976.
tumour in a dog. J Small Anim l'ract 37:597, 1996. 90. Poulet PM. et al: A survey of epithelial odontogenic tumors and
6(). Kaugars GE, et al: Odontomas. Oral Surg Oral Met/ 0.-al Parhol cysts in dogs ami cats. Vrr Pathof 29:369, 1992.
67:172, 1989. 91. Proffit WR. Field& IIW: Comemporary Orthodonrics, 3rd ed.
61. Killian CM, Croll TP: Dental twinning annmalies: The nomenclature Mosby-Year Book, St. Louis, 2000.
enigma. Quintessmce lnt 2/:571, 1990. 92. Reicharr PA, et al: Periodontal disease in the domestic em. A histo-
62. Kostlin R, ct al: Zur 0\igodontie und Schmelzhypoplasie beim Hund pathologic study. J l'eriodonral Res 19:61. \984.
[Oligodontia and enamel hypoplasia in dog]. Kleintierpraxis 27: 93. Rcicharr PA, et al: Epulides in dogs. J Oral Pathol Med 18:92,
II. 19!12. 19X9.
63. Kramek BA, et al: Diagnosis and removal of a demigerous cyst 94. Rossman LE, el a\: Disorders of teeth. In Harvey CE (ed): Veteri-
complicated by amelobla.,tic fibro-odontoma in a dog. J Vet De11t nary Dt'nlistry. WB Saunders, Philadelphia, 1985, p 79.
13:9, 1996. 95. Saphir DA, Carter GR: Gingival flora of lhe dog with special refer-
64. Kramer TRH, el al: Histo/oflical Typi1111 of Odomogenic ence to bacteria associated with hiles. J Clin Micmhiof 3:344. 1976.
2nd ed. Springer-Verlag, New York, 1992. 96. Schlup D: Epidemio\ogische und morphologis<.:he Untersuchungen
65. Kuiper JD, van der Gaag J: Caries. emailhypoplasie en tandvcrklcu- am Katz.engehiss. I. Epidemiologische Untersuchungen [Epidemio-
 Oral Pathology 2651

logical and morphological studies of dental disea.,es in cats. I. Epi· Hauskat:te [Observations on so·called anodontia in a .:at]. Zentra/bl
demiological survey]. Kleimierpraxis 27:87, 191!2. Veterinarmed A 12:193, 19M.
97. Schlup D, Stich H: Epidemiologische und morphologische Untcrsu· 116. Valentine BA, Eckhaus MA: Peripheral giant cell granuloma (giant
chungen am Katzengebiss. II. Morphologische Untersuchungen der cell epulis) in two dogs. Vet Parhol 23:340, 1986.
"neck lesions" [Epidemiological and morphological investigations of 117. van Wessum R, et al: Feline dental resorptive lesions. Prevalence
the Leeth of cats. II. Morphology of "neck lesions''). KleimiapraxiJ patterns. Vet Clin North Am Small Anim Pract 22:1405, 1992.
27:179, 191.!2. 118. Verstraete PJM: Anomalous development of the upper third premo-
98. Schneck GW: Caries in the dog. J Am Vet Med Assoc 150:1142, lar in a dog and a cat. J S Afr Ver Assoc 56:131, 1985.
1967. 119. Verstraete PJM: Dental pathology and microbiology. In Slatter D
99. Schneck GW: A case of enamel pearls in a dog. Iter H.ec 92:115, (cd): Textbook of Small Animal Sur11ery. 2nd ed. WB Saunders,
1973. Philadelphia, 1993. p 2316.
100. Schneck GW, Osborn JW: Neck lesions in the teeth of cats. Vet Rec 120. Verstraete FJM: Self·Assessment Color Review of Veterinary Den-
99:100. 1976. listry. Iowa State University Press, Ames, 1999.
101. Schneider LC, Weisinger E: The true gingival fibroma. An analysis 121. Verstraete FJM, et a!: Diagnostic value of full·mouth radiography in
of 129 fibrous gingiva11esions. .I Periodonto/ 49:423, 1978. cats. Am .I Vet Res 59:692. 1998.
102. Shafer WG, et a!: Cysts and tumors of odontogenic origin. In Shafer 122. Verstraete FJM, ct al: Diagnostic value of full·mouth radiography in
WG, et a! (cds): A Textbook of Oral Pathology, 4th ed. WE Saun· dogs. Am J Vel Res 59:61!6, 1998.
ders. Philadelphia, 1983, p 258. 123. Verstraete FJM, et al: The histological nature of epulides in dogs. .I
103. Shafer WG, et al: Dental caries. In Shafer WG. et a! (cds): A Comp l'atho/106:169, 1992.
Textbook of Om/ Pathology, 4th ed. WB Saunders, Philadelphia, 124. Verstraete PJM, Terpal: CH: Anatomical variations in the dentition
1983, p 406. of the domestic cat. J Ver Dent 14:137, 1997.
104. Shafer WG, et a!: Developmental disrurbances of oral and par.toral 125. Vos JH, et al: A feline dental tumor resembling calcifying epithelial
strm.:tures. In Shafer WG, et al (eds): A Textbook of Ora( Pathology, odootogenic tumor in man. Vet Patho/ 22:508, 19!!5.
4th cd. WB Saunders, Philadelphia. 1983, p 2. 126. Vos JH, van der Gaag I: Canine and feline oral-pharyngeal tumours.
105. Shafer WG, et al: Regressive alterations of the teeth, In Shafer WG, Zentralbl Veterinarmed A 34:420, 1987.
et al (eds): A Textbook of Oral Pathology, 4th cd. WB Saunders.
127. KM, et al: Epithelial odontogenic tumours in ani·
Philadelphia, 1983, p 318.
mals. .I Comp Pathol97:503, 1987.
106. Shigcyama Y, er a!: Expression of adhesi<m molecules during tooth
128. Walton RE, et al: fntemal bleaching of teeth in
resorption in feline reeth: A model system for aggressive
dogs. .I Endod 9:416, 1983.
activity. J Dent Res 75:1650, 1996.
107. Skrentny TT: Preliminary study of the inheritance of missing teeth 129. Walton RE, et al: Exterrtal bleaching of tetracycline stained teeth in
dogs. J Endod 8:536, 1982.
in the dog. Wien Tierarzt/ Mrmar.m:hr S/:231. 1964.
108. Stabholz A, Sela M.\1: The role of oral microorganisms in the patho· 130. Waner T, Nyska A: Gingival in dogs. Compend Conrin
Educ Pract Ver 13:1207, 1991.
genesis of periapical pathosis. I. Effect of Streptococcus mutans and
its cellular constituents on the dental pulp and periapical tissue of B I. Watts A, Paterson RC: Migration of materials and microorganisms
cats. J Entlod 9:171, 1983. in the dental pulp of dogs and rats. J F.ndod 8:53, 1982.
109. Stebbins KE, et a!: Feline oml neoplasia: A ten.year survey. Vet 132. Wegner W: Congenital tooth anomalies [dog]. J'rakt Tierarzt 68:19,
Patho/ 26:121. 1989. 1987.
110. Ten Care AR: Oral Hisrolofly: Deve/opmem, Structure. and Fun1.·· 133. White RA, Gorman NT: Wide local excision of acanthomatous epu·
tion, 5th ed. Mosby- Year Book, St. Louis, 1998. Jides in the dog. Ver Sur11 18:12, 1989.
Ill. Thrall DE: Orthovoltage mdiother.tpy of acanthomatous epulides in 134. White RAS, et al: Clinical staging for oropharyngeal malignancies in
39 dogs. JAm Vel Med Assoc 184:K26, 1984. the dog. J Small Anim Pmct 26:581, 1985.
112. Thrall DE, et al: Malignant tumor formation at the site of previously 135. White RAS, et a!: Sarcoma development following irradiation of
irradiated acanthomatous epulides in four dogs. JAm Vet Med Assoc acanthomatous epulis in two dogs. Vet Rec I 18:661!, 191!6.
/78:127, 19KI. 136. Wiggs RB: Bleaching vital teeth in canines. J Vet Dem 5:15, 191\l!.
ll3. Todoroff RJ, Brodey RS: Oral and pharyngeal neoplasia in the dog: 137. Wiggs RB: Bleaching nonviral teeth in canines. J Vet Dent 6:9,
A retrospective survey of 361 cases. JAm Ver Med As.wc 175:567, 198,9.
1979. 138. Wissdorf H. Hermanns W: Persistierende Milchhakcnzanne (Cd) im
114. Trowbridge HO, et a!: Structures and functions of the dentin and Oherkiefer einer Hauskatze !Persistent milk teeth (canines) in the
pulp complex. !11 Cohen S, Burns RC (eds): of the Pulp. upper jaw of a cat]. Kleimierpraxis /9:14, 1974.
8th ed. Mosby. St. Louis, 2002, p 411. 139. Zerner K. Steurer I: The influence of dry food on the development
115. Ucbcrbcrg H: Beobachtungen einer sogenannten Anodontie bei einer of feline neck lesions. J Vet Denr 9:4, 1992.
CHAPTER
196
Periodontal and Oral Inflammatory Disease
Cecilia Gorrel
PERIODONTAL DISEASE
Periodontal disease is the most common oral disease in
dogs, 12 and it is common in cats.4() Periodontal disease is a
collective tetm for many plaque-induced inflammatory le-
sions that affect the periodontium. Gingivitis is inflamma-
tion of the gingiva and is the earliest sign of disease.
Animals with untreated gingivitis may develop periodonti-
tis. The inflammatory reactions in periodontitis result in
destruction of the periodontal ligament and alveolar bone.
The end result of untreated periodomitis is exfoliation of
the tooth.
Periodontal disease can cause discomfort to affected ani-
mals. There is strong circumstantial evidence that a focus
of infection in the oral cavity may cause disease of distant
organs. 2 Consequently, prevention of periodontal disease is
important for the general health of companion animals.
Anatomy of the Periodontium
The periodontium attaches the tooth to the jaw and pro-
vides a suspensory apparatus resilient to nonnal functional
forces. It is made up of the gingiva, periodontal ligament,
cementum, and alveolar bone. (See Chapter 194.)
Clinically healthy gingiva shows no signs of inflamma-
tion. The gingiva is pale pink (unless pigmented), is not
swollen, and does not bleed on gentle probing. Sulcus
depths are within normal limits for the species. Histological
examination of clinically healthy gingiva reveals a mild
chronic inflammation (i.e., what is known as clinically
healthy gingiva is mildly inflamed).
Cause
The primary cause of gingivitis and periodontitis is accu-
mulation of dental plaque on the tooth surfaces. Contrary
to common belief, calculus (tartar) is only a secondary
cause.
Dental Plaque
Dental plaque is a biofilm composed of aggregates of
bacteria and their by-products, salivary components, oml
debris, and occasional epithelial and inflammatory cells.
Plaque accumulation starts within minutes on a clean tooth
surface. The initial accumulation of plaque occurs supra-
2652
gingivally but extends into the sulcus and populates the
subgingival region if left undisturbed. Supragingival plaque
bacteria derive their main nutrients from saliva. As shown
in a study in which dogs were fed by intubation, the
formation of dental plaque has little to do with food debris. 4
Within the sulcus or pocket, the major nutritional source
for bacterial metabolism comes from the periodontal tissues
and blood.
Accumulation of plaque on the tooth surfaces reproduc-
ibly induces an inflammatory response in associated gingi-
val tissues; removal of plaque leads to disappearance of the
clinical signs of this inHammation.-n. 4 '' At first, a direct
relationship was assumed to exist between the total number
of accumulated bacteria and the amplitude of the patho-
genic effect. Such a view of dental plaque as a biomass is
referred to as the plaque As it
became evident that not all gingivitis lesions invariably
progressed to periodontilis, the specific plaque hypothesis
was developed; in this hypothesis, the view is that perio-
dontitis is caused by specific pathogens. 25
The term infection refers to the presence and multiplica-
tion of a microorganism in body tissues. Periodontal dis-
ease is a unique infection in that it is not associated with a
massive bacterial invasion of the tissues. Infections caused
by the normal microflora are called opportunistic infections
if they occur at the usual habitat of the microorganisms.
S uch infections may be the result of changed ecological
conditions or may be due to a decrease in host resistance.
Most microorganisms in periodontitis plaque can also be
found occasionally in low proportions in health. These or-
ganisms may be viewed as putative opportunistic patho-
gens. A few suspected periodontal pathogens rarely occur
in the mouths of healthy individuals and may be consid-
ered exogenous pathogens.
Differences in the composition of the subgingival plaque
have been attributed in part to the local availability of
blood products, pocket depth, redox potential, and Po 2•
The question of whether the presence of specific microor-
ganisms in patients or distinct sites may be the cause or
consequence of disease continues to be controversiaJ.<IO
Many microorganisms considered as periodontal pathogens
are strict anaerobes and may contribute little to the initia-
tion of periodontitis in shallow gingival pockets. Instead,
these organisms are linked to progression of disease in
sites with preexisting disease, rather than initiation of dis-
case at shallow sites.
The formation of plaque involves two processes- initial
adherence of bacteria and continued accumulalion of bacte-
ria owing to a combination of multiplication of already

attached bacteria and further aggregation of bacteria to
those cells that already are attached. The peUicle alters the
charge and free energy of the tooth surface, which in-
creases the efficiency of bacterial adhesion. Specific bacte-
ria, such as Streptococcus sanguis and Actinomyces visco-
sus, can adhere to the pellicle. These bacteria produce
extracellular polysaccharides, which aggregate other bacte-
ria that are not otherwise able to adhere.
The plaque associated with clinically healthy gingiva is
composed mainly of aerobic and facultative anaerobic bac-
teria. In dogs with clinically healthy gingiva, the Actinomy-
ces-to-Streptococcus ratio in dental plaque is 2, whereas
this ratio is reversed in humans. 2 H As gingivitis develops,
plaque extends subgingivally. Aerobes consume oxygen,
and a low redox potential is created, which makes the
environment more suitable for growth of anaerobic species.
The aerobic population does not decrease, but with increas-
ing number of anaerobes, the aerobic-to-anaerobic ratio de-
creases. Coaggregation reactions with Actinomyces species
or other gram-positive bacteria are beneficial for the attach-
ment of gram-negative bacteria, such as Bacteroides spe-
cies. The subgingival flora associated with periodontitis is
predominantly anaerobic and consists of Porphyromonas,
Prevotella, Peptostreptococcus, Fusobacterium, and spiro-
chetes. Hi Anaerobes constitute about 25% of the culturable
subgingival flora in dogs with clinically healthy gingiva
and about 95% in dogs with periodontitis. High levels of
Porphyromonas and spirochetes are consistently associated
with progressive periodontitis in dogs.
The first bacteria to adhere to the pellicle are aerobic
gram-positive organisms. In dogs and cats, the main bacte-
ria in supragingival plaque are Actinomyces and Strepto-
coccus. As the plaque thickens, matures, and extends fur-
ther down the gingival sulcus, the environment becomes
suitable for growth of anaerobic organisms, motile rods,
and spirochetes. The bacterial flora of the normal feline
gingival margin and the bacteria found in subgingival
plaque of cats with gingivitis and periodontitis are similar
to those found in humans and dogs under similar condi-
tions.'111• :n
Dental Calculus
Dental calclLius is mineralized plaque. An Wlmineralizcd
layer of viable bacterial plaque always covers calculus,
however. Supragingival and subgingival plaque becomes
mineralized. Supragingival calculus per se does not exert
an irritant effect on the gingival tissues. In monkeys, a
normal attachment may be seen between the junctional
epithelium and calculus if the cakulus surface had been
disinfected using chlorhexidine.24 Sterilized calculus may
be encapsulated in connective tissue without causing
marked inflammation or ahscess formation. 1 It has been
debated whether or not calculus may exert a detrimental
effect on the soft tissue owing to its rough surface. It has
been established, however, that surface roughness alone
does not initiate gingivitis.55 The importance of calculus in
periodontal disease seems to be its role as a plaque-reten-
tive surface. This is supported by well-controlled animaPH
and dinicaP6• 39 studies showing removal of subgingival
plaque on top of subgingival calculus results in healing of
Periodomal and Oral Inflammatory Disease 2653
periodontal Lesions and maintenance of healthy gingival
and periodontal tissues.
Pathogenesis
The pathogenic mechanisms involved in periodontal dis-
ease include (I) direct injury by plaque microorganisms
and (2) indirect injury by plaque microorganisms via in-
flammation. The microtlora in periodontal pockets is in a
continual slate of flux; periodontitis is a dynamic infection
caused by a combination of bacterial vectors that change
with lime. As a result, the molecular events that trigger and
sustain the inflammatory reactions constantly change. Many
microbial products have little or no direct toxic effect on
the host; instead they have the potential to activate nonim-
mune and immune inflammatory reactions that cause the
tissue damage_ It is now well accepted that it is the host's
response to the plaque bacteria rather than microhial viru-
lence per se that directly causes tissue damage. 19
In many instances, disease progression may be an epi-
sodic occurrence rather than a continuous process. Tissue
destruction occurs as acute bursts of disease activity fol-
lowed by relatively quiescent periods. The acute burst is
characterized clinically by rapid deepening of the periodon-
tal pocket. as a consequence of detachment of periodontal
ligament fibers from root cementum and loss of alveolar
bone. The quiescent phase is not associated with clinical or
radiographic evidence of disease progression. Complete
healing does not occur during lhis quiescent phase because
subgingival plaque remains on the root surfaces, and in-
flammation persists in the connective tissue. The inactive
phase often lasts for extended periods. Other conditions,
such as physical or psychological stress and malnutrition,
may impair protective responses, such as the production of
antioxidants and acute-phase proteins, and can aggravate
periodontitis but do not cause destructive tissue inflamma-
tion. A genetic predisposition to destructive inflammation
of the periodontium may be important in some individuals.
In humans, a strong association has been observed between
the severity of periodontitis and a specific genotype of the
interleukin·l gene cluster. 22 Patients carrying this periodon-
titis-associated genotype may show phenotypic differences,
as indicated by elevated levels of interleukin-lP in gingival
sulcular (crevicular) fluid. 5 No similar data are available for
the dog or cal.
Plaque Control
Significance
Undisturbed plaque accumulation resu)L<; in gingtvttls.
Although some animals with untreated gingivitis develop
periodontitis, not all do so. It cannot be predicted which
animals with gingivitis will develop periodontitis. Animals
in which clinically healthy gingivae are maintained do not
develop pcriodontitis.23 Consequently the aim in periodon-
tal disease prevention and treatment is to establish and
maintain clinically healthy gingivae to prevent periodon-
titis.
Conservative or cause-related periodontal therapy con-
Z654 Dentistry
sists of removal of plaque and calculus and any other
remedial prC>cedures required, under general anesthesia, fol-
lowed by daily maintenance of oral hygiene. In animals
with clinically healthy periodontal tissues, the goal is to
prevent all gingivitis and consequently periodontitis. In ani-
mals with g ingivitis, the aim is to restore the tissues to
clinical heallh; in animals with established periodontitis
lesions, the aim of therapy is to prevent progression of
disease.
Toothbrushing
Mechanical plaque control is the mainstay of periodontal
disease prevention and therapy, with adjunctive chemical
plaque control being indicated in some situations. In hu-
mans, the most effective means of removing plaque is
frequent, preferably daily, toothbrushing; this is also true
for dogs.52· 53
The efficacy of toothbrushing depends on client motiva-
tion and ability and on animal cooperation. Every attempt
should be m ade to introduce toolhbrushing as part of the
animal 's daily routine. Most animals accept toothbrushing
if it is introduced gradually and in a nonthreatening fash-
ion, especially in young animals.
There are innumerable toothbrush head and handle de-
signs and sizes available, but there is insufficient evidence
to recommend any particular one. The choice of brush
should be based on the effectiveness of plaque control in
the hands of each individual. In general, a small soft-to-
medium texture nylon filament brush seems to be the most
comfortable.
There is no one correct method of brushing but rather
the appropriate one that in each case removes plaque effec-
tively without damaging either tooth or gingiva. A particu-
lar method must be dictated by individual preference and
dexterity and the variable dentogingival morphology occur-
ring with different of disease. In most instances, a
combination of roll and miniscrub technique achieves the
objective.
It is possible to remove plaque by toolhbrush alone, but
this is laborious and time-consuming. Toothpaste is used in
combination wilh toothbrushing for ( 1) facilitating plaque
removal, (2) increasing animal cooperation because of a
pleasant taste, and (3) applying agent'> to the tooth surfaces
for therapeutic or preventive purposes.
Diets and Chemical Agents
St:veral studies have investigated mechanical means of
reducing accumulation of dental deposits (plaque and cal-
culus) via dietary texture in the dog and cat.7-Jo. 17- 27 Al-
though modified dry diets and dental hygiene chews reduce
the accumulation of plaque and calculus and the severity of
gingivitis, they do not maintain clinically healthy gingivae
in the absence of toothbrushing. It has not been shown lhat
reducing the severity of gingivitis necessarily prevents the
development of periodontitis.
Aside from mechanically cleaning the teeth, food that
encourages chewing also stimulates salivary flow . Saliva
contains antibacterial agents, which help keep the mouth
clean. Chewing may help strengthen the alveolar bone and
periodontal ligament, reducing the risk of developing perio-
dontitis.
Numerous chemical agents have been evaluated for the
supplementation of mechanical plaque conlrol. Clinically
effective antiplaque agents are characterized by a combina-
tion of intrinsic antibacterial activity and good oral reten-
tion properties. Agents that have been evaluated include
chlorhexidine, essential oils, triclosan, sanguinarine, fluor-
ides, oxygenating agents, quaternary ammonium com-
pounds, substituted amino-alcohols, and enzymes. The
greatest effect on reduction of plaque and gingivitis can be
expected from chlorhexidine, essential oils, triclosan. and
substituted amino-alcohols. Antiplaque agents delivered
from toothpastes, gels, or mouth rinses can augment me-
chanical oral hygiene to control the formation of supragin-
gival plaque and the development of early periodontal dis-
ease. None of these agents prevents gingivitis on its own
(i.e., in the absence of mechanical plaque removal). All
agents are associated with adverse side effects, these ef-
fects vary according to the chemical agent and include
poor taste, a burning or numbing of oral mucous mem-
branes, staining of teeth and soft tissues, and allergic reac-
tions. The use of chemical antiplaque agents is adjunctive
to mechanical removal of plaque.
Role of Antibiotics
Regular mechanical removal of dental plaque is accepted
as the primary means to prevent and stop the progression
of periodontal disease . If periodontal disease is caused by a
limited number of bacterial species, IUld this hypothesis has
yet to be proved, nonspecific continuous plaque suppres-
sion by mechanical means is not the only possibility for
disease prevention and therapy. Specific elimination or re-
duction of pathogenic bacteria from plaque would become
a valid alternative. Before such an alternative can be advo-
cated, the question that needs to be answered is whether
antimicrobial (antiseptic or antibiotic or both) agent<; can
enhance the effect of mechanical plaque removal or even
be a substitute for it.
There are some specific features of periodontal disease
that suggest treatment by antimicrobial agents alone is not
sufficient. First, there is generally a lack of bacterial inva-
sion of the tissues in periodontal disease. Bacteria in the
subgingival plaque interact with host tissues even without
direct tissue penetration. For any microbial agent to have
an effcd, there is the requirement that the agent is avail-
able at a sufficiently high concentration not only within,
but also in the subgingival environment outside the peri-
odontal tissues. Second, periodontal pockets contain many
different bacteria. This may cause problems for antimicro-
bial agents to work properly because they may be inhib-
ited, inactivated, or degraded by nontargel microorganisms.
Third, $ubgingival plaque is a biofilm. and biofilms effec-
tively protect bacteria from antimicrobial agenl-;. Finally,
most microorganisms associated with periodontal disease
frequently can be detected at low numbers in the absence
of disease. In the therapy of opportunistic infections, elimi-
nation is not a realistic goal. Successfully suppressed puta-
tive pathogens are likely to grow back if favorable ecologi-
cal conditions (e.g., deep periodontal pockets) persist.

Continuous control of ecological factors is necessary after
initial treatment.
Antibiotic agent-; may be delivered by <lirect placement
into the periodontal pocket or by the systemic route. Each
method of delivery has specific advantages and disadvan-
tages. Local therapy may allow application of an agent at a
concentration that cannot be achieved by the systemic
route. Local application may be particularly successful if
the treatment of target microorganisms is confined to clini-
cally visible lesions.
Alternatively, systemically administered agents may
reach widely distributed microorganisms. Studies in hu-
mans have shown that periodontal bacteria may be distrib-
uted throughout the mouth in some patients, including non-
dental sites, such as the dorsum of the tongue or tonsillar
crypts.34. 3s. 3?. 54 Disadvantages of systemic antibiotic ther-
apy relate to the fact that the drug is dispersed over the
whole body, and only a small portion of the dose reaches
the subgingival flora. Also, adverse drug reactions are more
likely to occur if drugs are distributed systemically.
In vitro tests cannot be correlated directly to clinical
efficacy because they do not reflect the true conditions
found in periodontal pockets. In particular, they do not
account for the biofi lm effect. As a consequence, demon-
stration of in vitro susceptibility is no proof that an agent
works in treatment of periodontal disease. The ultimate
evidence for the efficacy of systemic antibiotics must be
obtained from longer term treatment studies in animals
with periodontitis.
There are many similarities between human and canine
periodont.al disease. Consequently, data from human studies
do have relevance to canine periodontal disease. Various
antibiotic regimens have been tested for treatment of hu-
man patients not respon<ling to conservative periodontal
therapy. Favorable short-term effects have been reponed;
however, a great variability in treatment response between
patients has been noted. Reemergence of putative patho-
gens has been observed and has been considered the reason
for recurrence of disease.
Antimicrobial treatment is of secondary importance in
the treatment of periodontal disease compared with me-
chanical removal of dental deposits and periodontal pocket
management. Where follow-up mechanical plaque control
is instituted successfully, no benefit can be shown as a
result of including antimicrobial therapy with mechanical
debridement compared with mechanical debridement
alonel6 ; however, in dogs for which no postoperative home
care is provided , there is a demonstrable long-term retarda-
tion effect after short-term antimicrobial therapy. 42 Conse-
quently, systemic antimicrobial therapy cannot be recom-
mended as prevention and first-Hne treatment of
periodontal disease for any species and definitely not in the
absence of mechanical periodontal therapy. Systemic anti-
microbials are an accepted and useful adjunctive modality
in treatment of periodontal disease in specific situations
(e.g., severe local infection, dangers of bacteremia to a
systemically ill or immune-compromised individual).
In practical terms, systemic antibiotic therapy may be
given preoperatively, during surgery, and postoperatively.
Preoperative antibiotic administration aims to reduce in-
flammation before periodontal therapy, reducing bacteremia
1'
and Oral lnfl.:tmmatory Disease 2655
at the time of treatment, and provide the surgeon with
healthier tissue to work with. The purpose of perioperative
antibiotics is mainly to reduce the treatment-induced
bacteremia, whereas poswperat1ve antibiotic administration
aims to optimize healing of the tissues by reducing the
bacterial load. Preoperative or perioperative antibiotics are
indicated for specific situations, such as a systemically ill
or immune-compromised animal in which treatment-in-
duced bacteremia needs to be reduced. Reducing the bacte-
rial load postoperatively to aid healing is achieved best by
mechanical or chemical plaque control, rather than sys-
temic antibiotic therapy.
Gingivitis
Gingivitis occurs when plaque-induced inflammation of
the periodontium is limited to the gingiva. It is completely
reversible.
Clinical Signs and Diagnostic Methods
Gingivitis manifests clinically as swelling, reddening,
and often bleeding of the gingival margin. It is diagnosed
clinically by visual inspection and tactile examination. The
presence and degree of gingival inflammation are assessed
based on a combination of redness and swe11ing and pres-
ence or of bleeding on gentle probing of the gingi-
val sulcu.<l. Various indices can be used to give a numerical
value to the degree of gingival inflammation present. In the
clinical situation, a simple bleeding index may be the most
usefuL Using this method, the gingival sulcus of each tooth
is probed gently at several points and given a score of 0 if
there is no bleeding and a score of 1 if the probing elicits
bleeding. An index that relies on visual inspection and
bleeding, the modified LOe and Silness gingival index, can
also be used (Table 196- 1). 31 In research, this index is the
most commonly used method of a.,;sessing and quantifying
gingivitis. The gingival index is measured at the mesiobuc-
cal, midbuccal, ctistobuccal, and palatal/lingual aspects of a
tooth. At each of these locations, the gingival margin is
assessed and given a score (see Table 196-l). The re-
corded scores are added together and divided by the num-
ber of surfaces scored to give a mean gingival index for
each tooth, specific type of tooth, quadrant, or the whole
mouth.
Table 1 96-1 . Modified Gingival Index of L.Oe and
Sllness3 1
Gingival index 0 Clinically healthy
Gingival index 1 Mild gingivitis: slight reddening and swelling
of the gingival margin; no bleeding on
gentle probing of rbc gingival sulcus
Gingival index 2 Moderale gingivitis: The gingival margin is
red and swollen; gentle probing of the
gingival sulcus results in bleeding
Gingival index 3 Severe gingivitis: The gingival margin
swollen and red or bluish red: there is
spontaneous hemorrhage or ulceration of
the gingival margin
2656 Den£1stry

Consequences
Uncomplicated gingivitis generally is not associated with
pain or discomfort in humans. It is an insidious disease,
and the patient may be unaware of its existence. The signif-
icance of gingivitis is that if untreated, periodontitis may
develop as described earlier.

Treatment Options
Removal or adequate reduction of plaque restores in-
flamed gingivae to health. When clinically healthy gingivae
have been achieved, these can be maintained by daily re-
moval or reduction in the accumulation of plaque.
Toothbrushing is the most effective means of removing
plaque. In dogs with experimentally induced gingivitis and
in naturally occurring gingivitis, daily toothbrushing is ef-
fective in returning the gingivae to health. 52• 53 In a 4-year
study in beagles, with no oral hygiene, plaque accumulated
rapidly along the gingival margin with gingivitis develop-
ing within a few wceks. 23 Dogs that were fed an identical
diet under identical conditions but were subjected to daily
toothbrushing developed no clinical signs of gingivitis. In
the group that was not receiving daily toothbrushing, gingi-
vitis progressed to periodontitis in most animals.
Although mechanical removal of plaque by toothbrush-
ing is the mainstay of human dental hygiene, most dog
owners do not brush their dogs' teeth regularly. Conse- Figure 196- 1. A. Lnrge amount\ of plaque and calculus make it
impo"1ble to the severity of periodontitis. B. The periodontal
quently, mechanically reducing plaque accumulation by de\lruct10n i' evident when the dental deposits have been removed.
means of dietary texture becomes an important pan of
preventive dental care in the dog. Several studies investi-
gated the local effect of diet on plaque formation and new lesions at other sites and to prevent further tissue
development of gingivitis in dogs. A coarse diet may re- destruction at sites that already are affected.
duce plaque accumulation on some teeth and on some
tooth surfaces.' A study done over a 6-month period inves-
tigating oral cleansing by dietary means showed that dogs Clinical Signs
consuming a test diet• had significantly less plaque, calcu- Halitosis is common and is often the first sign noted by
lus, and gingival inflammation than the control group. 27 the pet owner. Large amounts of dental deposits arc usu-
Similarly the daily usc of a dental hygiene chewt for dogs ally present (Fig. 196- IA). It is only when these deposits
reduces accumulation of dental deposits and reduces gingi- have been removed that a detailed examination of the peri-
vitis in short-tcm1 and long-term studies. 7- 9 The efficacy of odontium can be done and the full extent of destruction
a dental hygiene chew* for dogs with a rubbery rather than can be assessed (Fig. 196- 18). A detailed examination of
hard texture has been shown. 10 The efficacy of an oral the oral cavity (teeth and periodontium) is possible only
hygiene chew* for cats also has been validated. 17 with the animal under general anesthesia. Gingival reces-
sion (Fig. 196- 2) and exposed root surfaces may be obvi-
ous. Ulcers affecting mucous membranes of lips and
Periodontitis checks may be present in areas where these tissues are
exposed to plaque-covered tooth surfaces.
Individuals with untreated gingivitis may develop perio-
dontitis. The inflammatory reactions in periodontitis result
in destruction of the periodontal ligament and alveolar Diagnostic Methods
bone. The end result of untreated periodontitis is exfolia- Tissue destruction in periodontitis is assessed by many
tion of the tooth. Periodontitis is a site-specific disease parameters. The factor that must be evaluated for each
(i.e., it may affect one or more sites of one or several tooth are periodontal probing depth at several sites around
teeth). Periodontitis can generally be considered irrevers- the circumference of the tooth (Fig. 196-3), evidence of
ible. The aim of treatment is to prevent development of gingival recession, evidence of furcation involvement (Fig.
196-4), and degree of tooth mobility. Radiography to vi-
"Pre.,cnption Diet Canine tid. Hill"'> Pet Nutrition, Tnc., Topeka, Kan. sualize the extent and rype of alveolar bone destruction
' Marketed a> Pedigree DentaRask in Europe and as Pedigree Dentabone mandatory. In many cases, measuring or calculating the
in United States; Mars Inc.. McLean. Va.
'M:arketed u• Pedigree Rancho in Europe and Waltham Tartar Chew
periodontal attachment level is also useful. All findings are
in the United Stutes. Mtm, Inc., McLean. Va. recorded on a dental chan.
•Whiska;, Dcntahits, Mar' Inc., McLean, Va. Periodontal Probing Depth. The depnh of the sulcus
 Periodontal and Oral Inflammatory Disease 2657

Figure 196-2. Gingival recession and exposed root surfaces laden

with dental deposits and other debris are apparent on this maxillary
canine tooth; note the ulcer of the mucous membrane of the lip. (Counesy
of Dr. F. Verstraete.)

can be assessed by gently inserting a graduated periodontal

probe until resistance is encountered at the base of the Figure 196-3. A, Periodontal probing depth is measured by insening a
sulcus. The depth from the free gingival margin to the base periodontal probe into the gingival sulcus until firm resist.ance is felt. The
of the sulcus is measured in millimeters at several locations distance from the free gingival margin to the depth of the sulcus or
around the whole circumference of the tooth. The probe is pocket is the periodontal probing depth. It should be measured at several
s ites around the circumference of each tooth. 8 , The probe has been
moved gently horizontally, walking along the floor of the placed on the surface of the gingiva to depict the depth to which it had
sulcus. The gingival sulcus is I to 3 mm deep in the dog been inserted.
and 0.5 to l mm in the cat. Measurements greater than
these values usually indicate the presence of periodontitis.
The destruction of the periodontal ligament and alveolar
bone resorption allows the probe to be inserted to a greater
depth. The term used to describe this situation is periodon-
tal pocketing. All sites with periodontal pocketing are re-
corded on the dental chart. Gingival inflammation resulting
in swelling or hyperplasia of the free gingiva also results in
measuring sulcus depths in excess of normal values. In
these situations, the term pseudopocketing is used because
the periodontal ligament and bone are intact (i.e., there is
no evidence of periodontitis), and the increase in periodon-
tal probing depth is due to swelling or hyperplasia of the
gingiva.
Gingival Recession. Gingival recession is also measured
in millimeters from the cementoenamel junction to the free
gingival margin. At sites with gingival recession, periodon-
tal probing depth may be within normal values despite
periodontitis.
Furcation Involvement. Furcation involvement refers to
the situation in which the bone between the roots of multi- Figure 196-4. Gingival recession and grade 3 furcation involvement
rooted teeth is resorbed as a result of periodontitis. The of the maxillary second premolar are ev ident.
 2658 Dentisrry

furcation sites of multirooted teelh should be examined

with either a periodontal probe or a dental explorer. The
grdding of furcation involvement is listed in Table 196-2.
Tooth Mobility. The extent of toolh mobility is assessed
using a suitable i'n strument. It is not assessed using fi ngers
directly because the y ield of the soft tissues of the fingers
masks the extent of tooth mobility. The grading of mobility
is listed in Table 196- 3.
Radiography. Dental radiography to visualize the extent
and type (i.e., horizontal or vertical) of alveolar bone de-
struction is o1andatory. Radiography also allows identifica-
tion of endl>dontic or other complications. Horizontal bone
loss results in a suprabony pocket, whereas vertical bone
loss results in an infrabony pocket. Tnfrabony defects are
diagnosed by a combination of exploration with a peri-
odontal probe (the probe meets lhe fim1 resistance of bone
when angled away from the tooth) and radiography. They
are described by depth and by the extent of the bony
circumference involved. The surrounding alveolar bone is
thought of as forming four walls (mesial, buccal, distal,
palatal/Lingual). When bone is present around the entire
circumference of the pocket, a four-wall defect is present.
When bone is missing on one face, a three-wall defect is
present. T wo-wall and one-wall defects have two and three
surfaces of the tooth root without bony support (Fig.
196-5).
Periodontal Attachment Level. Periodontal probing
depth is not necessarily correlated with severity of attach-
ment loss. Gingival hype rplasia may contribute to a deep
pocket (or pseudopocket if there is no attachment Joss);
gingival recession may result in the absence of a pocket
but also minimal remaining attachment. Periodontal attach-
ment level r ecords the distance from the cementocnamel
junction (or from a fixed point on the tooth) to the base or
apical extension of the pathological pocket. It is a more
accurate assessment of tissue loss in periodontitis. Peri-
odontal attachment le vel can be measured with a periodon-
tal probe, or it can be calculated (e.g., periodontal attach-
ment level + g ingival recession).
Consequences
Based on feedback from human patients, uncomplicated
periodontitis is not associated with severe pain or discom-
Table 1 96- 2. Grading of Furcation Involvement
Table 196-3. Grading of Tooth Mobility
Grade 0 N(l mobility
Grade 1 Horizontal movement of s 1 mm
Grade 2 Horizontal movement of 1 mm•
Grade 3 Vertical and horizontal movement is po:;sible
·Multirooled teeth """" sc,·erety. and a horizontal mobility >I DIDJ is
u......ny ron'idered a grade 3 even in the absence of vettical m<wemcnl
fort. Tn contrast, complications. such as lateral periodontal
abscess or ulcers in the mucous membranes, can be painful.
A severe infection in the oral cavity, as with extensive
periodontitis, leads to a transient bacteremia on chewing.50
An association has been shown l:!ctween periodontal dis-
case and histopathological changes in kidney, myocardium,
and liver. 2
Treatment Options
Home care is an important aspect in the treatment of
periodontitis. After periodontal therapy under general anes-
thesia, the client must remove or reduce the accumulation
of plaque daily. Tt often useful to implicate daily tooth-
brushing before the periodontal treatment. Most animals
require a 3- to 4-week training period before they accept
having ail teeth in one sitting. Some animals will
not accept toolhbrushing, and the periodontal treatment of
such cases is more radical. Adjunctive use of a topical
antiplaque agent, ideally chlorhcxidine gluconate, is often
required.
The effect of dental dict'i or dental hygiene chews in
animals with periodontitis has not been investigated. It is
wtlikely that such products are effective in treating peri-
odontitis because lhey do not remove plaque below the
gingival margin.
Periodontal surgery is never the first treatment for peri-
odontitis. Conservative lherapy, consisting of thorough !>U-
and subgingival scaling, root planing, polishing,
irrigation, and daily meticulous home care, is the first step.
Periodontal surgery is indicated only when the client has
shown the ability to keep the teeth clean. lf a client cannot
t !
h1
l \0 I

Grade 0
Grade I
No furcation involvement
h1icial fuTCatinn involvement the furcatioo can be fell
\
with r.hc probe/explorer, hut horizootal tissue
destruction is thlll1 one third of rbe horizootal
\.
!\[';\\
I
\
\
\
\
me
Grade 2
width of furcation
P3.rtial furcation involvement: lt is possible to explore
the furcation, but Lhe cannot be
\
%):'\\ \
through it from huccal to palatal/lingual.
Horizontal tissue destruction is more than one third B!,
)I} .
·1:,

Y"' t
I
of the horizontal width of the furcation
Grade 3 Total furcnlion involvement: The probe/explorer can Figure 196- 5 . Classification of osseous defects. A. One-walled. R.
I be passed through the furcalion from buccal to Two-walled. C, Three-walled. D. "Cup" lesion. (From Tsugawa AJ, Vcr·
straete fJM: How to obtain and imerpret periodontal in dogs.
L palatal/lingual
Clin Tech Small Anim Pmct /5:204, 21100.)
 Periodontal and Oral Inflammatory Disease 2659

Figure I 96-6. Algorillun for deciding whether a

loolh arfected by periodontitis is treatable.

Continue homecare
Re-examine in 3- 6 months
I Extract I
Re-treat as indicated

maintain good dental hygiene measures in his or her pet in cosal inftanunatory inn ltratc cons1stmg of plasma ce lls,
the interest of the well-being of the animal, there is no lymphocytes, macrophages, and neutrophils. 1-'· •x· 41 The ele-
indication for surgery. An algorithm for deciding whether a vated serum globulins in affected cats and the nature of the
tooth is treatable is depicted in Figure 196-6. submucosal inflammatory infiltrate led many authors to
suggest that there may be an immunological basis for the
condition.•x. 43• 5 M To date, no underlying intrinsic immuno-
Logical abnormality has been identified ; however, the con-
DISEASES dition still may he immune mediated. Clinical studies have
implicated the potential involvement of various viral
Periodontal disease is the result of the inflammatory re- agents, calicivirus in particular,••. :w, 21 • 47 • 51• 56· 59 and gram-
sponse to dental plaque (i.e., oral bacteria) and is limited to negative anaerobic bacterial sped es.29 • 44· 45 Attempts to re-
the periodontium. A spectrum of inflarrunatory to
agents other than plaque (e.g., toxic, viral, and unknown)
also occurs in the oral cavity. These generally affect the
oral mucous membrane but also may involve the periodon- Table 196-4. Nonperiodontal Oral Inflammatory
Diseases
tium. Inflammation of the oral mucosa is called stomatitis.
Conditi ons associated with Necmti:e.ing ul ccrntivc gingivostomatitis
immune system Mycotic infections (commonl y
Oral Inflammatory Conditions or
Neutrophil dysfunction, gra y collie
syndrome, drug therapy. viral
Table 196-4 lists the most important oral inflammatory in fection (e.g .. FeL V)
conditions other than periodontal disease. AuToimmune discrders Vcsiculobullous skin diseases (e.g.,
pemphigus and pemphignid)
or discoid lupus erythematosus
Sjiigren-like syndrome
Feline Chronic Gingivostomatitis H ypersensitjvity Drug eruptions
Insect stings
Feline chronic gingivostomatitis is a poorly defined syn- Viral infections Fel.V
drome of unknown cause, characterized by focal or diffuse PTV
Calic.ivims
chronic inflammation of the gingiva and oral mucosa."· 111• sK
Miscellant:nus ccmditions Eosinophili c granuloma complex
Commonly described clinical findings in cats with feline Feline chronic gingivostomatitis
chronic gingivostomatitis include elevated serum globulins;
predominantly hypergammaglohulinemia 57• 60; and a submu- FeLV, feline vii\Is; H V, fcliw.: immunodeficiency vims.
2660 Dentistry
Figure 196- 7 . The inflammation, which commonly is called faucitis,
is confined largely to the palatoglossal folds and regions lateral to the
folds.
produce the disease using these putative infectious etiologi-
cal agents have been unsuccessful.
Clinical Signs
Feline chronic gingivostomatitis can occur clinically as
focal or diffuse inflammation. Patterns of clinical presenta-
tion have been identified as follows.l 4
Feline leukemia virus/
feline immunodeficiency
virus positive
IFull-mouth extraction 1+- - - - - - - - '
Gingivitis with Stomatitis. The gingival inflammation
extends past the mucogingival junction onto the buccal and
less often palatal/lingual mucosa. Lesions are usually sym-
metrical, and the premolar and molar regions are likely to
be more inflamed than the incisor and canine regions.
Stomatitis with Gingivitis. The inflammatory reaction is
more intense in the rest of the oral mucous membranes
than in the actual gingivae. ln particular, the palatoglossal
folds are inflamed, but there may be extensive ulceration or
granulation of the gingival or buccal mucosa. The mucosa
of the hard palate or the tongue rarely is affected. Affected
cats are more likely to exhibit signs of oral discomfort than
cats with predominantly gingivitis.
Faucitis. The term faucitis is a misnomer. By definition,
the fauces is the region medial to the paaatoglossal folds.
The inflammation that is commonly called faucitis is
largely confined to the palatoglossal folds and regions lat-
eral to the folds (Fig. 196- 7). On close inspection, there is
nearly always evidence of gingivitis in the premolar and
molar regions.
Diagnosis
Cats with chronic stomatttts require a thorough evalua-
tion before any treatment (Fig. 196-8). The purpose is not
to reach a diagnosis but rather an attempt to identjfy possi-
ble underlying causes. Such evaluation includes testing for
feline immunodeficiency virus and feline leukemia virus,
routine hematology and blood biochemistry, and sometimes
biopsy and microscopic examination of the affected tissues.
Radiographic evaluation to identify the presence of odonto-
clastic resorption lesions or other lesions is mandatory.
Systemic diseases (e.g., chronic renal failure and diabetes
mellitus) !hat may predispose to the development of severe
Figure 196-8. Treatment options for feline chronic
gingivostomatitis.

gingival inflammation in the presence of plaque must also
be excluded before any treatment is initiated.
Treatment Options
Historically the intractable nature of £he disease, in com-
bination wilh a poor understanding of the cause of feline
chmnic gingivostomatitis has resulted in the v.-idcspread
use of empirical symptomatic treatment regimens; however,
their efficiency has rare ly been documented. In one study,
various treatment regimens, including chlorhexidine rinses,
antibiotics, corticosteroids, and gold salts, were investigated
over a 6-month periodP In the shorl-tenn, methylpredniso-
lone was the most effective regimen. Over the long-term,
the individual clinical responses were diverse, and none of
the treatment regimens showed superiority.
A total of 30 cats with feline chronic gingivostomatitis
were treated by extraction of most or all of the premolar
and molar teeth. 15 Of the 30 cats, 24 (80%) were improved
significantly or clinically cured at the time of follow-up, 11
1.0 24 months after treatment.
Based on the aforementioned studies, lhe current treat-
ment recommendations for cats with feline chronic gingi-
vostomatitis include a combination of period<mtal therapy
and a home care regimen whereby plaque accumulation is
kept to a minimum. ln some cats, this approach may result
in a reduction in inflammation. Many cats do not cooperate
adequately with home care measures, and plaque reforms
beyond a critical leveL These cats need extraction of pre-
molar and molar teeth. ln some cals, all teeth may require
removal.
Cats with chronic gingivostomalitis are usually extremely
uncomfortable. Every attempt is made to identify and elim-
inate or treat any underlying cause for the intense oral
inflammation. Full-mouth radiographs arc a mandatory
component of diagnosis. Initial treatment consists of a
combination of periodontal therapy and home care. Corti-
costeroid or antibiotic therapy also may be required. In
ca')es in which home care is inadequate or refractory, ex-
traction of teeth is the treatment of choice.
References
1. Allen DL, Kerr DA: Tissue reNponse in the guinea pig to sterile and
non-sterile calculus. J Periodontol 36:121, 1965.
2. DcBowes U. et al: of periodontal di sease and histologic
lesions in multiple organs from 45 dogs . .I Vet Denr 13:57, 1996.
3. Egclbcrg J: Local effet:LN of diet on plaque formation and gingivitis
development in I. Cffect of hard and dices. Odont Re-..-y /6:
3 1, 1965.
4. Egclberg J: Local effects ot" diet on plaque formation and gingivitis
development in 2. Effect of frequency M meals and tube feed-
ing. Odont Revr 16:50, 1965.
5. Engebretson SP. et al: The inftucnce of interleukin gene polymor-
phism on el\pression of interlcukin·lJ3 and tumor necrosis factor-a in
period{mtal and gingival crevicular lluid. J Periodontal 70:567,
1999.
6. Gaskell RM, Gruffydd-Jones TJ: Intractable feline stomalilis. Vet An·
nual 17:195, 1977.
7. Oorrel C. Bierer T : Long tenn effects of a dental hygiene chew on
the periodontal health of J Vet Dent 16:109, 1999.
R. Gorrcl C, Rawlings JM: The role of a 'dentul hygiene chew' in
maintaining periodontal health in dogs. J Vet Dent 13:3 1, 1996.
Periodontal and Oral Inflammatory 2661
9. Gorrel C, Rawlings JM: The role of tooth-bru shing and diet in thc
maintenance or periodontal health in dogs. J Vet Dent 13:139, 1996.
10. C, et al: Effect of a new dental hygiene chew on periodontal
health in dogs. J Vet Dent 16:77, 1999.
II. Oruffydd-Jones TJ: Gingivitis and stomatitis. In August JR ted): Con-
sultations in Pellne lf!lernal Medicine. WB Philadelphia,
1991 , p 387.
12. Hamp SE, et al: A macroscopic and radiologic investigation of dental
diseases in Vet Radiol25:86. 1984.
13. Harley R. ct a\: Clinical and inununological tlndings in feline chronic
gingivoscomatitis . In : Proceedings, lith BVDA Annual Scientific
Meeting. British Veterinary Dental Association. Binningham, United
Kingdom, 1999.
14. Harvey CE: Feline orRI pathology. diagnosis and management. In
Crossley DA, Penman S {eds): Manual of Veterinary Dentistry. Brit-
ish Small Animal Veterinary Association. Gloucestershire. t.:K, 1990.
p 129.
15. Hennet P : Chronic gingivo- stomatitis in cats: Lnng tenn follow-up of
30 cases treated by denta1 . .T VL't Dent 14: 15, 1997.
16. HeMet PR, Harvey CE: Anaerobes in periodontal disease in the
A review. J VL't Dent 2 :1\. 1991.
17. fngham KE, et al: The evaluation of a new dental hygiene chew on
the periodontal health of cats. In: Prot:£•£•dings, 12th BI'DA Annual
Scientific Maring. Veterinary Delltal Association, Birming-
ham. Unill:d Kingdom, 2000.
18. Johnessee JS, HurviLY. AI: Feline plasma cell gingiviti s-pharyngitis. J
Am Anim Ho.sp As.vnc /9:179, 1983.
19. Ki!Wle DF. Lindhe I : Pathogenesis of periodontitis. Tn: Lindhe J, el
al (eds): Cliniwl Periodontology and Implant Dentistry. Munksgaard,
Copenhagen, 1997, p 189.
20. Knowles JO, et al: Prevalence of feline calicivirus, feline leukaemia
vilus and to FlY in cats with chronic stomatitis. Vet
/24:336, 1989.
2 1. Knowles JO, et al: Studies on the role <lf calich•irus in chronic
stomatitis in l' cc Microbiol27:205, 1991.
22. Kornman KS, et al: The intcrlcukin I ge.n otype a severity factor in
adult peri odonllll disease. J Clin Paiodanrol 24 :72, 1997.
23. Lindhe J, et al: Plaque induced periodontru disease in Beagle dogs : A
four year clinical, roentgenographical and histometrica1 study . .T P£·r·
iodonrol Res 10:243, 1975.
24. Listgarten MA, Ellegaard B: Electron microscopic evidence of a cel-
lular attachment between junctional epithelium and dental . .I
Pe>·iodontol Res /1:143, 1973.
25. Loesche WJ: Clinical and microbiological 1\Spects of chemotherapeu-
tic agents to !be specific plaque J Dent
Res 58 :2404, 1979.
26. Loesche WJ: Rationale for the use of antin1icrobial agents in peri-
odontal disease. / nt J Techno/ Assess Health Care o:403, 1990.
27. Logan E: Oral deun.ving IJy dil'lary means: Results of _,;x month
sllldies. Proceedings, Conference on Companion Animal Oral Heallh,
University of 1996.
28. Loret J: F.mde de /' in 1•ivo in virro de l' as.wr:iution spiramy·
c:ine-metronidawle sur Ia jiore parodontale apres induction cxpcri-
memule ll' une paradonrite chez le chien. de doctorat en Pilar-
made. C:niversit6 Paol Sabatier, Toulouse , 1990.
29. Love ON, e t a\: Bacteroides species from the oral cavity and oral
assuciated diseases of cats. Ver Microbiol /9:275, I 989.
30. Love DN, et al: TI1e obligative and facultatively anaerobic bacccriru
flora of the normal Jeline gingival margiu. V;•t Micru/Jiul 22:267,
1990.
3 1. Li:ie H: The g.ingival index, the plaque index :Uld the retention index
system. J f'eriodantol 38:610, 1967.
32. L& H, cr 1\l: Experimental in mnn. J Periodontol 36: 177.
1965.
33. Mallonee DH, et al: Bacteriology of periodontal disease in the Cllt..
Arch Oral Bioi 33:671, 1988.
34. Mombclli A, et al: Actinobacillus actin()m)'Ce!;•mcomirans in ndult
periodontitis: l. Topogr.tphic distribution before and after treatment. J
Periodon.tol 65:820, 1994.
35. Mombelli A, e1 al: Black pigmenting gram-negative b acteria in peri-
odontal disease: I. Topographic distribution in the human dentition. J
Periodomol Res 26:30 1, 199l.
36. Mombelli A. et n\: Clinical and changes associated
with an altered subgingival enviJ·onment induced by periodontal
pocket reduction. J Clin Periodontol 22:780, 1995.
2662 Dentistry
:n. Muller HP, et al: Simultaneous isolation of Actinobacillus ar.tinomy-
cell!mcomitans from subgingival and locations of Ute
mouth. J Clin Periodomol 22:413, 1995.
3ll. Nyman S, et al: Role of "diseased" root cementum in healing follow-
ing treatment of periodontal disease: An experimental study in the
dog. J Periodomol Res 21:496, 1986.
39. Nyman S, et al: Role of "disea<;ed" rol>t cementum in healing lolll>W-
ing treatment of periodontal disease: A clinical study. J Clin Perio-
donrol 15:464, 1988.
40. Reichart PA, ct al: Periodontal disease in the domestic cat: A histo-
pathologic study. J Periodonr Res 19:67, 1984.
4 1. Reindel JF, et al: Recurrent plasmU(;ytic stomatitis-pharyngitis in a cat
with esophagi tis, fibrosing gastritis and gastric nematodiasis. J Am Vet
Med Assoc 190:65, 1981.
42. Sarkiala E, ct al: The efficacy of tinidazole in naturally occwTing
periodontiti s in dogs: Bacteriological ami chemical results. Vet M icrQ-
buJI .l6:2:13. 1993.
43. Sato R, et a\: Oral administration of bovine lactoferrin for treatment
of stomatitis in feline immunodeficiency virus (FIV)-posi-
tive and FJV-negative cats. Am J Vet Res 10:1443, 1996.
44. Sims TJ, et al: Serum antibody to antigens of oral gram-
negative bacteria in cats with plasma cell gingivitis-stomatitis. J Delli
Rt.t 6.9:877, 1990.
45. Sims TJ, et al: Serum antibody responses to antigens or gram-
negative bacteria in the <.:at. Arch Oral Bioi 33:677, 1988.
46. Socransky SS, et a!: Difficulties encountered in the search for the
erjologic agents of periodontal I Clin Periodonrol
14:5!!!! , 1987.
47. Tenorio AT, ct al: OJTOnic oral infection of cats and !heir relati onship
to pcr.;istcm ordl carriage of feline cal ici. immunodeficiency. or leu-
kaemia viruses. Vet /mmunQl /mmunoparh 23: I , 1991.
4M. Thcilnde E: The non-specific theory in microbial etiology of inftam-
mutory periodontal J Clin Periodonro/13:905, 191\6.
C H A P T E R
197
Periodontics
T. Keith Grove
Treatment of advanced periodontal disease is primarily
surgical. Medical treatment to counter bacterial infection
and eliminate destructive intlammalion shows promise but
requires root debridement for long-term effectiveness.
Some practitioners restrict themselves to nonsurgical peri-
odontal therapy because of the technical difficulty of doing
advanced procedures (see "hygiene phase" for a description
of nonsurgical therapy). Where pockets are deep, surgical
treatment improves access to the roots for exposure and
mechanical removal of accretions. Similarly, increasing
width of tooth surface and architectmal variations in tooth
morphology caused by fissures, furcations, and restorative
margins increase the difficulty of thorough scaling and root
planing that is not facilitated by surgical e.xposure. 23 A
surgical approach also can be used to resect abnormal tis-
sue and regenerate support that was lost as a result of
periodontitis. Ruling out surgery can limit results in moder-
ate and advanced periodontal disease.
49. Theilade E, et at: Experimental gingivitis in man: ll. A longitudinal
clinical and bacteriological investigation. J Periodoruol Res 1:1, 1966.
50. Thoden van Vclzcn SK, et al: Plaque and systemic disease: A reap-
praisal of the focal infection J Clin Periodontol 11:209,
1984.
51. Thompson RR, ct a!: Association of calidvirus infection with chronic
gingivitis and pharyngitis in cats. J Small Anim Pract 25:207, 19!!4.
52. Tromp JA, et a!: Gingival health and frequency of in
the Beagle dog model: Oinical findings. J Clin Periodomol 13: 164,
1986.
5:1. Tromp JA, et al: Experimental gingivitis and frequency of lOOih-
brushing in the Beagle dog m,>ckl. Clinical findings . .I Clin Ptriodon-
tol 13:190, 1986.
54. Van Winkelhoff AJ , et al: fntra-ural distribution of black-pigmented
Racteroides species in periodontitis patients. Oral Microbiol lmnumol
3:&3. 19&&.
55. Waerhaug J: Effect of rough upon gingival tissues. J Oem
Res 35:32:1, 1956.
56. Waters L. et al: Chronic gingivitis in a colony of cats infected with
feline immunodeficiency virus and feline calicivirus. Ver Rec 132:340,
1993.
57. White SD, et al: Plasma cell in cats: 40
( 1973-1991). JAm Vet Med A.uoc 200:1377, 1992.
58. Williams CA, Aller .MS: GingivitiS/5tomatitis in cats. Vet Clin Nonli
Am Small Anim Pract 22:1 361, 1992.
59. Yamamoto JK. et at : Epidemiologic and clinical aspects of feline
immunodeficiency virus infection in cats from the continental United
S tates and Canada and possible mode of transrnissioo. JAm Vet Med
As.voc: 794:213, \989.
60. Zetner K, et al: Comparative immunological and virological studies of
chronic oral diseases in Wim Tierarztl Monat.!schr 76::103.
19!!9.
TREATMENT PLANNING
Preventive Therapy
Periodontal disease is preventable if the teeth can he
kept clean (see Chapter 196). Hygiene is important for all
patients. Initiation of hygiene control in patients at sexual
maturity is good preventive medicine. Tooth brushing, anti-
septic mouth rinses, and regular professional periodontal
cleaning are recommended to keep the teeth clean to pre-
vent disease.
Systemic Phase
Systemic problems that predispose patients to periodontal
disease must be identified. Diabetes mellitus resulting from
 Periodontics 2663

defects in neutrophil function decreases resistance to peri-
odontal infection. AU animals should have a physical ex-
amination and appropriate laboratory testing to ensure that
systemic problems do not affect the successful surgical
treatment of periodontal disease. When identified, systemic
diseases that require treatment must be controlled or re-
solved before surgery (Fig. 197 -I).
Hygiene Phase
Initial periodontal treatment involves removing plaque
and calculus from the teeth above and below the gingival
margin. This treatment allows some resolution of inflam-
mation and, depending on the degree of damage, may be
sufficient to control periodontal disease.9· 15
Ultrasonic scaling with copious water irrigation is the
fastest method of removing gross accretions from the teeth.
A universal tip can be used to reach most areas. The
instrument is held with a pen grasp and moved lightly up
and down the surface of the tooth to avoid overheating or
gouging the surface. Because the root surface is softer than
the crown, it is important not to use the point of the
instrument against the root. After all visible calculus,
plaque, and stains are removed, the instrument is inserted
to the depth of the gingival space. It is withdrawn at each
stroke to remove dislodged debris. When the surface of the
tooth feels smooth and clean, ultrasonic debridement is
complete.
After ultrasonic scaling, the root is probed with an ex-
plorer to identify residual roughness or calculus that was
missed. These areas are smoothed with a curette until hard

Tooth fracture
below gingival
margin

Scaling and
hygiene
instruction

Scaling, root Scaling, root Above Below

planing, and planing, and gingival gingival
hygiene hygiene attachment attachment
instruction instruction

Recall Recall Soft tissue

surgery
exposure
Pockets Pockets still
not bleeding bleeding
or less or more
than 5 mm than 5 mm
Recall

;J

i:•
i
I
I

Figure 197 -I. Options lor periodontal treatment in dogs.

2664 Denristry
and even (Fig. 197 - 2). Particular attention is paid to feel-
ing for calculus in the furcations, at the cementoenamel
junction, at the depth of the gingival sulcus, and at the line
angles (e.g., rostral-buccal or caudal-lingual sutface) of the
teeth because these are the areas where most operators
miss calculus. 5
After being thoroughly cleaned and smoothed by scaling
and root planing, the teeth are polished. Smooth surfaces
accumulate less debris and arc easier to clean in the future
because the calculus cannot interlock mechanically with the
tooth. The prophylaxis angle attached to a slow-speed
handpiece polishes efficiently. Polishing occurs slightly un-
der the gingival margin if a rubber cup is loaded with
polishing and pressed gently against the tooth as it
rotates in the handpiece. The teeth remain moist during
polishing to minimi:r.e overheating.
Alternatively, an air-polishing unit can be used for pol-
ishing. lt uses medical-grade sodium bicarbonate crystals
and water in a jet of compressed air to sandblast the
surface smooth. Air polishing has many advantages, espe-
cially for veterinary use. It is an effective means of polish-
ing. Air polishing involves no physical contact with the
tooth, and thermal injury is of no concern, contrary to cup-
and-pumice polishing. Air polishing is ideally suited for
polishing teeth separated by wide diastemata and with con-
siderable variations in shape and size. Areas that are diffi -
cult or impossible to reach with the rubber cup can be
polished easily using the air polisher.
After the cleaning, the mouth is irrigated, and the patient
is discharged with a 2-week supply of 0.05% to 0.2%
chlorhexidine solution. Clients are instructed to rinse the
mouth twice daily for 30 seconds with this solution to
allow healing with minimal bacterial contamination. 111• 2 1
B Surgical treatment is indicated when pockcl depth is
Figure 1 97-Z, Curette engaging the mot surface at the bottom of a
periodontal pocket to begin planing the root and d ean after gross
scaling with an deaner. A, Periodontal pocket. 8,
<.lehris. C. Curette in cross-section.
Tooth brushing can begin the day after cleaning. About 1
month after cleaning, reevaluation occurs, and any neces-
sary periodontal surgery is done. The healing that occurs
during the month after thorough cleaning may be enough
to resolve the gingival inflammation and the bleeding on
probing. Even when pocket depth is greater than 5 mm at
reevaluation , surgery is not necessary if bleeding on prob-
ing and inflammation have resolved. Patients that arc no
longer inflamed are cleaned in 3 to 6 months. Many ani-
mals respond to this therapy.
NONSURGICAL PERIODONTAL
TREATMENT
Patients whose disease is still active (bleeding on prob-
ing) after the hygiene phase of treatment may be treated
more conservatively if practitioners are not comfortable
with surgery. The results may not be as good as with a
more sophisticated approach but may be bener than stop-
ping at the hygiene phase. The most common and best
nonsurgical treatment is to debride the roots much more
frequently (e.g., every 3 months) during professional peri-
odontal cleaning appointments. Antiseptic rinses delivered
by the client, especially rinses containing chlorhcxidine,
and professional flushing below the gingival margin arc
another option. Slow-release antiseptic chips can be used
for site-specific treatment but are impractical for patients
with many teeth affected by advanced disease. Antibiotics,
especially when pocket culture and sensitivity results are
used for guidance, can be helpful if used systemically or
better by local delivery systems to the pocket itself. Local
delivery systems currently are being investigated, and the
first products have been introduced to the marketplace.
Suppression of destructive enzymes by oral administration
of chemically modified antibiolic.<; with no antibacterial or
dmg-resistance effects is another treatment option. !n gen-
eral, these methods work better for the treatment of relaps-
ing patients that have had adequate surgical debridement
and with time begin to because of inadequa(e main-
tenance or emergence of refractory disease. Often advanced
cases with deep pockets lhal were treated nonsurgically
relapse into active disease quickly because t he root surfaces
were never adequately debrided.
SURGICAL PHASE
5 mm or greater and bleeding on probing does not resolve
ufter thorough tooth cleaning (see Fig. 197-1 ) _13 It also
may be indicated for soft tissue and bone grafts. Most
surgical patients have deep pockets with inflammation after
tooth cleaning and reexamination in 1 month. ln general,
surgical provides better access to the root surface
so that hidden calculus can be exposed and removed. 5 If
residual inflammation is present after scaling and if the
initiating calculus can be identified and removed without
surgery, surgery is unnecessary. The initiating factors for
and periodontal disease are on the root surt'ace12 nol in the soft
tissue; soft tissue surgery in itself is not corJ'ective.

PERIODONTAL SURGERY
lnvers•Bevel Repositioned Flaps
for Root Debridement
The goal of inverse-bevel repositioned flaps is to retlect
the soft tissue away from the teeth, remove granulation
tissue around the roots, and thoroughl y clean the roots
down to the periodontal attachment?
Technique
The procedure st3Jt.<; with an incision in the gingival
sulcus, beginning at the free gingival margin and extending
to the alveolar margin (Fig. 197 -3). The incision is ex-
tended around all affected teeth in that area and connected
interdentally so that buccal and lingual flaps can be raised
(Fig. 197 - 4). A sharp periosteal elevator is used to reflect
the soft tissue past the mucogingival junction. Granulation
tissue is removed from the underside of the flap with cu-
rettes, scissors, or tissue nippers. The rootl> are irrigated,
surrounding granulation tissue is removed, and all calculus
and root roughness are eliminated with curettes. Fine ab-
sorbable sutures are used to oppose flap edges between the
teeth, and the flaps are returned to their former level
(hence the term repositioned). Moist gauze is compressed
against the gingiva, which adapts the underside of the flap
to the teeth. This practice eliminates dead space that could
delay healing and encourage down-growth of epithelium
into the space.
Aftercare
During the first 2 weeks after surgery, the dcnlogingival
junction is irrigated with 0.05% to 0.2% chlorhexidine
twice daily for 30 seconds. Although resolution of inftam-
f'igure 197-3. U$ed in flap surgery. A, Inverse-bevel intrasul-
cular incision. B. lnven<e-bevel incision for apically flap.
Periodontics Z665
,
I \'A
I
I
\-+-8
I
\ I
\
/
'/ .....
I
I
\
Figure 197-4. view of three caudal teeth Wld inci.sion outline
for flap surgery. (The line is drawn at the level of the alveolar
.crest-not the free gingiva.) A, Vertical releasing incisions (if necessary
for exposure). B , Incision around the teeth. C, Occlusal view of teeth.
mation ordinarily occurs after periodontal surgery, the ac-
cumulation of bacteria on the teeth eventually reestablishes
inflammation in the area. Surgical patients should undergo
periodontal cleaning every 3 to 12 months, depending on
intlammatory level, to prevent recurrence of disease.4 Cli-
ents are encouraged to brush the patient's teeth daily and
provide a hard diet or chew toys. All periodontal surgery
patients arc treated the same postoperatively, despite differ-
ences in surgical procedure. When compliance with home
care and recall for scal ing are not expected, surgery is not
done; thorough cleanings are scheduled on a regular basis.
lnvers•Bevel Apically
Positioned Flaps for Pocket
Reduction
Inverse-bevel apically positioned flaps are indicated to
expose the root surface, decrease pocket depth, and in-
crease the amount of attached gingiva. They are produced
by making an incision around the neck of the teeth 1 to 3
mm away from the free gingival margin (see Fig. 197-3).
This incision is directed toward the alveolar process so that
it undermines the gingiva adjacent to the tooth. Other oper-
ations are similar to inverse-bevel repositioned flaps for
root debridement except that the edges of the flap are
returned to just above the alveolar margin, rather than
repositioned to the former location. This apical placement
of the free gingival margin eliminates soft tissue pockets
and reduces the depth of infrabony pockets that have pro-
nounced soft tissue component above them. Also, the mu-
cogingival junction is positioned apically so that the
amount of attached gingiva is not reduced.
2666 DentiStry
Osseous Flap Surgery
Osseous flap surgery is similar to inverse-bevel flap sur-
gery, but the intent is bone exposure. The goal is to elimi-
nate infrabony pockets by resecting the alveolar bone or to
smooth an irregularly contoured alveolar process. The pri-
mary difference between this operation and other flap oper-
ations is that it involves bone removal. No better prognosis
has been reported with pocket elimination. 10 This operation
seldom is used except for treating deep pockets with intrac-
table inflammation below the bony margin that borders
them. Osseous flap surgery is done primarily for access,
and ledges of bone are removed with chisels, rongeurs, or
carbide burrs (see Fig. 197 - 6). When supporting bone is
removed, the operation is called ostectomy. When nonsup-
porting bone is removed to eliminate pockets by improving
flap adaptation, the procedure is called osteoplasty.
Crown Lengthening
When teeth are fractured below the gingival margin.
normal tooth structure must be exposed to allow accurate
restoration. This operation involves removing bone and soft
tissue to reposition the margins of a flap below the fracture
line. Flap elevation is the same as reverse-bevel flap sur-
gery, but bone is removed so that apical positioning of the
flap allows supragingival exposure of the fracture line. The
flap may need to be thinned at the margins to avoid exces-
sive bone removal. The fracture line must be at least 5 mm
above the alveolar margin to allow connective tissue at-
tachment and epithelial adhesion over bone. Failure to
leave enough space between bone and restorative margins
predisposes to poor healing.
Gingivectomy
Gingivectomy eliminates periodontal pockets through ex-
cision of excessive tissue above the alveolar margin, pro-
vided that this can be achieved without eliminating all the
attached gingiva. Pockets extending below the alveolar
margin contraindicate gingivectomy when tissue removal
results in abnormal re1·erse architecture that accumulates
debris. The operation is begun by marking the depth of the
pocket on the attached gingiva by applying pressure with a
periodontal probe. The incision is started below the marks
and is directed toward the depth of the pocket on the tooth.
The resected tissue is removed with tissue nippers and
curettes, the area is irrigated, and the roots are cleaned.
Gingivoplasty
Gingivoplasty reshapes the gingiva. The operation is the
same as for gingivectomy except that the intent is to create
normal tissue contour rather than to resect soft tissue pock-
ets. It is useful in treating gingival hyperplasia in which
the gingiva needs to be recontoured (Fig. 197 -5). Patients
that accumulate plaque and calculus postoperatively fre-
quently have regrowth of excessive tissue.
Mucogingival Surgery
Mucogingival surgery increases the amount of attached
gingiva or repositions the attached gingiva and alveolar
mucosa. It is indicated when periodontal inflammation per-
sists after cleaning because of an inadequate barrier of
attached gingiva between alveolar mucosa and the peri-
odontal attachment to the tooth. A dehiscence over a root
caused by chewing hard objects and irritating restorations
is an indication for mucogingival treatment. Pedicle flap
surgery and soft tissue grafts arc types of mucogingival
surgery.
Pedicle Flap Surgery
Gingival recession over prominent roots may be treated
by rotating a pedicle of adjacent attached gingiva to the
denuded area. 14 First, the margins of the defect are excised
to expose gingival connective tissue. Next, a pedicle is
created, allowing a full-thickness mucoperiosteal flap to be
placed over the defect. Occasionally a frenulum must be
cut to keep lip movement from displacing a pedicle. The
risk of displacement can be evaluated by tugging on the lip
and looking for evidence of tension on the pedicle. When
necessary, the frenulum is incised down to bone to relieve
the tension, and the margins are sutured.
Soft Tissue Grafts
Soft tissue may be harvested from one area of the mouth
and transferred to bone or connective tissue in another area
to increase tissue at the new site. The recipient area is
denuded by sharp dissection and periosteal elevation. Next.
a donor site is chosen. The mucoperiosteum removed from
the recipient site and aluminum foil are used as a template
to harvest a partial-thickness (at least 2 mm thick) graft of
connective tissue. The graft is sutured to the recipient site
with fine, simple interrupted sutures. Wet gauze is used to
apply pressure adapting the graft to the recipient bone for
I minute to eliminate dead space. These grafts survive by
plasmatic circulation the first week and must be sutured to
intimate contact with the bed. When epithelium is trans-
ferred, it sloughs during the first 10 days. The lamina
Figure 197-5. Fibrotic gingiva wilhout pocke1 fonnation; thi\ cond• -
Jion may indicate gingivoplasty if the area is becoming inflamed becau \c
of debris rc1en1ion caused by a poor con1our.
 J
Periodontics 2667

propria confe.rs keratinizing potential on the graft. The ker-

atinizing nature of the lamina propria is genetically deter-
mined and survives in its new location to influence the
character of epithelium !hal migrates over it. As with pedi-
cle grafts, interfering frenula may be resected to eliminate
motion between the graft and the bed. Postoperative care is
the same a<; for other periodontal surgery except that care
is taken to ensure that the graft is not dislodged from the
recipient site by vigorous irrigation or by chewing hard
objects.

Reconstructive Surgery for

lnfrabony and Furcation Defects
Bone and Alloplastic Implants
Bone may be harvested from the patient (autograft), an-
other member of the same species (allograft), or a different
species (xenograft) and used as a framework for defect
closure in the host periodontium. 17 Autogenous cancellous
bone is most effective in stimulating regeneration of new
bone. Bone morphogenetic protein induces bone growth
and occurs in its largest usable concentration in fresh can-
cellous bone graft.<;. Freeze-dried bone allografts have been
successful and do not require a second surgical operation.
Concern over the transfer of disease and immunological
intolerance may prejudice some clients against this method.
Alloplastic (synthetic) materials also can fonn a scaffold
for bone growth. Processed coral, nonabsorbable synthetic
hydroxyapatite, absorbable hydroxyapatite, and tricalcium
phosphate are used for bone implants.
. Placement of a bone graft or implant is initiated by
inverse-bevel ftap exposure. The soft tissue in the bone
defect is removed, the roots are cleaned, and the defect is
filled with the chosen material (Fig. 197 -6). The flaps arc
adapted carefully to the teeth, and the patient is given
tetracycline for 3 weeks because complete wound closure
and use of antibiotics enhance graft success.2° Chlorhexi-
dine solution is used to irrigate the mouth for the first 2
weeks postoperatively, to decrease bacterial contamination
of the graft site. Evaluation of results is done after about I
year, with many cases not exhibiting maximal radiographic
bone growth until that time.
Guided Tissue Regeneration
When gingival connective tissue and epithelium can be
excluded from healing defects in the bone or furcation,
progenitor cells from bone or periodontal tissues repopulate
the dcfcct. 7 This process results in greater regeneration of
the defect with retum to notmal structure.6 • 19 When
these tissues arc not excluded from the healing defect, such
as occurs in conventional flap surgery, defects rarely fill
with bone and periodontal ligament.
The operation begins with elevation of a mucoperiosteal
flap. The infrabony defect or furcation le.'lion is debrided,
and the exposed roots are cleaned. Decalcifying the root
surface with citric acid for 3 minutes has been effective in
dogs to promote new attachment between healing periodon-
tal tissue and the tooth. Decalcification cleans and detoxi-
fies the root surface, exposing collagen in the dentin. 2• 22
All cementum must be removed for the dentin coHagen to
Figure 197-6. Alternatives fur IIWlagement of iofrabony periodontal
p ockets after f!ap exposuTe. A. Osteoplasty to remove bony wall of
p<.>cket. B. Implanting bone or C. Membrane place-
l nent (da.\'hed line.) to exclude gingival epithelium during healing.
be exposed by citric acid; this removal usually is accom-
plished by thorough root planing. Tetracycline can be used
as an acid to dec ale ify the root surface. 11 One 250-mg
capsule of tetracycline hydrochloride is dissolved in 5 mL
of water, and ·this solution (with pH of 1) is applied for 3
minutes to the root surface with a paintbrush. Tetracycline
also may have some local antibiotic effect when used in
this manner. 1 After the root surface is prepared, the defect
may be implanted with bone or alloplastic material. Im-
plants added to defects before membrane placement im-
prove the amount of defect filling compared with place-
ment of a membrane only. Resorbable or nonresorbable
membranes may be used for this purpose. The membranes
have been developed for use in human teeth and are com-
mercially available. The membrane i$ trimmed to cover the
defect plus 2 mm of surroundin g bone, and it is sutmed
tightly around the root surface (see Fig. 197-6).
The Haps are replaced and sutured interdentally. Om!
chlorhexidinc rinses are used for 2 weeks, and systemic
tetracycline is administered for 3 weeks. A nonabsorbable
membrane is removed with a gentle tug in 4 to 6 weeks;
absorbable material is not removed. Daily home care and
professional supragingival cleaning every 3 months for the
tirst year are suggested. This operation is suggested for
regenerating deep infrabony defects on the palatal surface
of max ilJ ary canine teeth, where defects may extend to the
nasal mucosa.
MAINTENANCE THERAPY
Although most surgical therapy for periodontal disease is
initially successful in decreasing inflammation and perhaps
2668 Dentistry
in regenerating lost tooth support, active involvement in an
appropriate maintenance program is required for continued
success. Each patient has different requirements for how
often the dentition must be professionally cleaned. Varia-
tions are due to differences in disease severity at the begin-
ning of therapy, disparity in owner compliance with daily
home hygiene, and dissimilarities in host resistance to in-
fection.
One way to establish an appropriate recall interval is to
reexamine treated patients at 3-month intervals. If the clini-
cian recognizes established gingivitis and bleeding on sub-
gingival probing, the teeth are cleaned, and a new appoint-
ment is made for I month. If the gingiva is healthy I
month after cleaning, the recall interval is appropriate for
maintenance thempy to resolve recurrent gingivitis. If the
gingiva is unhealthy or if loss of attachment has occurred
since the last cleaning, the recall interval must be short-
ened. Most animals with severe periodontitis require clean-
ing approximately every 6 months. Animals that have not
lost much attachment often do well with annual cleaning.
Maintenance cleaning differs from initial therapy in that
subgingival scaling and root planing are not necessary in
noninftarned gingiva; however, supragingival scaling with
inspection of the subgingival environment for bleeding and
calculus is required. Only areas that bleed are scaled and
root planed subgingivally because repeated root planing
may initiate slight loss of gingival attachment. All teeth are
polished, and for 2 weeks, 0.05% to 0.2% chlorhexidine
rinses are used twice daily for 30 seconds.
Periodontal charting to determine areas of increased dis-
ease activity is helpful in following patients after treatment.
Measurements taken during recall scaling are compared
with initial status; loss of more than 2 mrn of attachment,
as evaluated by clinical probing, is significant and indicates
deteriorating status. Radiographs can be used in chronolog-
ically evaluating the attachment level on the rosu·al and
caudal slllfaces of teeth. Maintenance-phase radiographs
can be compared with initial radiographs. Where additional
loss of bone support can be appreciated, the disease has
progressed.
PERIODONTAL PROSTHETICS
When attachment loss has been extensive and mobility
of teeth prevents mastication without pain, the surgeon can
join teeth together and use their combined support to avoid
discomfort. Teeth selected for this procedure should have
noninflamt:d pt:riodontal status, increased mobility, and ra-
diographic signs of secondary occlusal trauma, and excel-
lent horne care should be ensured. Various methods have
been described. Individual crowns are constructed for the
involved teeth, and these are joined together by soldered or
cast joints. The splint is cemented as a unit to the involved
teeth. Incisors can be joined by dental acrylics or compos-
ite filling materials, alone or in combination with ligature
wire, fiberglass fibers, or ribbon-like materials. Another in-
dication for splinting teeth together is food impaction.
Food may become impacted between loose-touching teeth
(teeth without proper tight interdental contact) by opposing
teeth. The impacted material can tear the periodontal at-
tachment and initiate chronic periodontitis, which may lead
to tooth loss. These teeth can be joined together with cast
crowns, which prevent food impaction.
Splinting may be employed for a short period or perma-
nently. Whether splinting leads to any long-term biological
stabilization of teeth is controversial. Splinting may lead to
abnormal occlusal forces being exerted on the periodontal
ligament of the abutment teeth, which could be harmful.
Splints are plaque retaining, inhibit the natural cleansing
mechanism, and make adequate home care more difficult.
References
l. Al-Ali W, et al: The effect of local doxycycline with and without
tricalcium phosphate on the Tegenenative healing polential of peri-
odontal osseous defects in dogs . .I Perlodontol 60:5!12, 19!19.
2. Albair WB, et al: Connective tissue attachment to pcriodontally dis-
eased roots after citric acid demineralization. 1 Periodomol 53:515,
1982.
3. Ammons WF, Smith DH: Flap curettage: Rationale, technique, and
Dent Clin Norrh Am 20:215, 1976.
4. Becker W, et a!: Periodontal treatment without maintenance: A Tetro-
spectivc study in 44 patients. J Periodontol 55:505, 1984.
5. Brayer WK, et al: Scaling and root planing effectiveness: The effect
nf runt surfaee access and operator experience. J Periodontal 60:67,
1989.
6. Card SJ, et at: New attacluncnt following the usc of a resorbable
membrane in the treatment of periodontitis in dogs. lnt J Periodont
Resw'· Dem 9:58, 1989.
7. Caton JG, et a!: Periodontal regeneration via selective cell repopula-
tion. J Periodontal 58:546, 1987.
8. Claffey N. et al: Placement of a porous membrane underneath the
mucoperiosteal flap and its effect on periodontal wound healing in
dogs. J Clin Periodomo/16:12. 19!!9.
9. Const•nsus rt•pon discussion, Section II. World Workshop in Perio-
dontics. American Academy of Periodontology, Chicago, 1989, p II-
15.
10. Consen$US report discussion. Section IV. World Workshop in Perio-
dontics. American Academy of Periodontology. Chicago, 19!19, p IV-
24.
II. Frant'!: B, Polson A: Tissue inter.u:tions with dentin specimens after
demineralization using tetracydine. J Pe.riodontol 59:714, 1988.
12. Grove TK: Periodomal disease. Compend Coni Educ Prai'l Vet 4:564,
1982.
13. Gmve TK: Periodnntaltherapy. Compend Com Educ Praa Vet 5:660,
1983.
14. Hoag PM: Isolate areas of gingival recession: Etiology and treatment.
Calif Dent Soc Rev 72:27, 1979.
15. Loc H, et al: Experimental gingivitis in man . .f Periodont 36:177,
1965.
16. Killoy WI: Quantity, nature, and time required for recurrence of the
microbial ma•s irrigated from the periodontal pocket. J Am Soc Pre\'
Dent 6:11, 1976.
17. Mellonig IT: Bone grafts in periodontal therapy. NY State Dent .I 52:
27. 1986.
18. Niederman R, et al: Regeneration of furca bone using Gore-Tcx
periodontal material. lnt J Periodont Restor Den1 9:469, 1989.
19. Pfeifer I, et al: Epithelial exclusion and tissue regeneration using a
collagen membrane barrier in chronic periodontal defects: A histolog-
ical study. lm J Periodom Resror Dent 9:263, 1989.
20. IJ. e1 al; of freeze-dried bone in
periodontal osseous defects: Part III. Composite freel.e-dried hone
allografts with and without autogenous bone grafts. J Periodontol 54:
I, 1983.
21. Southard SR, et al: The effect of 2% chlorhellidine digluconate irriga-
tion on clinical parameters and the level of Bacteroides gingiva/is in
periodontal pockets. J Periodonto/ 60:302, 191!9.
22. Tanaka K, et al: The effect of citric acid on retained plaque and
calculus. J Periodontoi60:RI, 191!9.
23. Wcnnstrom J, ct al: Periodontal surgery: access therapy. In Lindhc J,
ct al (cds): Clinical Periodomolos:y and Implant Dentistry, 3rd ed.
Munksgaard, Copenhagen. !997. p 528.
CHAPTER
198
Endodontics
Patricia Frost Fitch
Endodontics deals with the pulp and periapical tissues.
The pulp consists of odontoblasts, blood vessels, nerves,
lymphatic vessels, and connective tissue and provides the
blood supply to the active odontoblasts on the periphery of
the pulp. 14 The nerve fibers are mostly sensory fibers,
which have small fibrils that extend into the dentinal tu-
bules. This partly explains the sensitivity of exposed den-
tin. Open and exposed dentinal tubules can lead to pulpal
pathosis.-1 The periapical tissue has sensory innervation as
well. Lateral and accessory canals may occur in the apical
third of the root canal and are uncommon in the dog and
cat. Odontoblasts are active in a vital tooth, laying down
additional layers of dentin after eruption as well as devel-
oping the apex. This dentin is called secondary dentin, and
its continual deposition as the animal ages narrows the
pulp cavity and strengthens the tooth. The tooth apex is
generally closed in dogs by 7 to 10 months of age and in
cats by 7 to 11 months of age. 18 Endodontic therapy is an
option for pulpal pathosis as an alternative to extrdction to
preserve a functional tooth strucrure.
INDICATIONS FOR
ENDODONTIC TREATMENT
Domestic and wild animals frequently traumatize their
tooth crowns. A common cause is chewing on hard ob-
jects, such as rocks, bones, prepared cow hooves, or other
hard play toys. Other causes are cage biting and accidental
trauma, such as collisions with a motor vehicle, baseball
bat, thrown rock, or animal kicks (Fig. 198-1 ). The classi-
fication of tooth fractures is described in Chapter 195.
Complicated crown fractures may be detected immediately,
in which case a partial coronal pulpectomy or "vital pul-
potomy" may be possible. Most go undetected until routine
examination, dental cleaning, or the animal shows clinical
signs. When there is trauma to the tooth crown, discolor-
ation, or deep caries, an endodontic procedure may be
indicated.
Endodontic disease may also occur secondary to ad-
vanced periodontal disease that progresses down the root to
affect the periapicaJ area, by exposure of the apex of a
tooth during mandibular fractures, or during jaw fracture
repair. Tooth luxation or avulsion that damages the blood
supply to the tooth also leads to pulp death. Discolored
crowns are often associated with pulp death secondary to
blunt trauma to the tooth that causes bleeding into the
dentinal tubules (Fig. 198-2). As the blood pigments break
down, the tooth is stained red, purple, and then brown-
gray-black. With mild trauma, the pulp may remain vital,
in which case only a mild color change in the tip of the
tooth may be evident. More commonly, the entire crown is
discolored. Tooth vitality can be confirmed with a dental
pulp tester along with radiographic changes to -confirm pulp
death. 12
Reduction of tooth crown height to relieve soft tissue
injury combined with a partial coronal pulpectomy is a
better treatme nt option than extraction for with man-
dibular drift after mandibulectomy, with linguoverted man-
dibular canines or malocclusion causing palatal trauma, for
lip trauma after maxillary canine tooth extraction, or with
traumatic malocclusion after mandibular fracture causing
trauma to the lips or hard palate (Fig. 19R-3).
PATHOGENESIS OF
ENDODONTIC DISEASE
When the pulp tissue becomes exposed secondary to a
complicated crown fracture, there is initial inflammation
and contamination of the pulp tissue. This inflammatory
response continues and increases with further exposure and
bacterial contamination, leading to a pulpitis. This leads to
periapical inflammation and pulp death. As the pulp tissue J.'I
undergoes necrosis, the exposed pulp hom appears black at j
the fracture site. The inflammation of the periapical tissues
leads to bone loss in the periapical region. As the periapi-
cal reaction increases, a periapical granuloma or abscess is :
formed. In time, there may be acute exacerbation of the ::
chronic inflammation with swelling, destruction of adjacent
bony tissue, and sinus tract formation.
Endodontic disease of the maxillary fourth premolar is
frequently associated with facial swelling or a draining
tract that erupts below the eye (Fig. 198 -4). The term
phoenix abscess refers to the acute flare-up of a chronic
periapical lesion. Fractured mandibular canine teeth that
become infected may drain ventrally through the skin or
laterally through the alveolar mucosa. It is also possible for
the infection to lead to draining tracts into the nasal <.:avily
adjacent to maxillary teeth or in the furcation area of mul-
t irooted teeth. These cases may have nasal discharge,
sneezing, or draining tracts apical to the mucogingival
junction over the tooth. 1n chronic cases, there can be
substantial inflammatory resorption of the root end, which
may lead to a poor prognosis for endodontic treatment.
Teeth may have a combination of periodontal and endo-
dontic lesions.4• 9 Advanced periodontal disease with exten-
sive vertical bone loss can lead to infection of the pulp
through lateral canals or the apical delta and is known as a
class II lesion (Fig. 198-5). Chronic endodontic disease
and periapical pathosis leading to secondary periodontal
disease is classified as a class I lesion and is usually distin-
2669
2670 Dentistry
Figure 1 98- 1. Complicated crown-root fracture ("slab fracture") of
right maxillary founh premolar.
Figure 198- 2 . Necrotic pulp removed from an intact discolored canine
tooth in a 4-ycar-old dog.
Figure 1 98- 3 . Traumatic malocclusion wilh mandibular canine tooth
creating a defect in the hard palate. One treatment option is crown
amputation with a paniul coronal pulpectomy to preserve some functional
tooth structu re and to eliminate soft tissue damage.
Figure 198-4. Infraorbital swelhng associated with a "phoeni'l" ab-
scess of the left maxillary fourlh premolar.
guished by evidence of coronal damage. A class In lesion
is a true combination of unrelated periodontic and endo-
dontic lesions. Pain associated with endodontic disease is
more difficult to evaluate in animals, and the lack of pain
is often realized after treatment of an infected tooth by
recognition of improvement of the demeanor or activity
level of the patient.
Figure 1 98- 5. Radiograph of a class IT periodontal-endodontic lesion
of both molar teeth.

DIAGNOSIS OF ENDODONTIC
DISEASE
Clinical signs and symptoms of endodontically diseased
teeth can vary from no overt signs to obvious signs of oral
discomfort with fresh crown fractures or advanced periapi-
cal abscessation. There is evidence of a bleeding pulp in
recent crown fractures or a black spot that can be probed
with an explorer tip with chronic pulp exposure. Pulp test-
ing or hot-cold sensitivity as used in the diagnosis of endo-
dontic disease in humans is more subjective in animals and
less reliable for evaluating pulp vitality. Facial or mandibu-
lar swelling and small draining tracts near the root apex of
an affected tooth may be seen. In cats, bulging, buccal
alveolar bone (alveolar osteitis) over the maxillary canine
tooth root can indicate endodontic disea c. This may be
seen with just a minor tip fracture of the crown. Discolored
teeth can be examined with a transilluminator directed
through the tooth. A dead tooth is dull and opaque. A vital
tooth is translucent with the pulp horn readily visible. On
occasion, nonvital teeth are noted only on radiographic
examination when a pulp cavity is wider than the contralat-
eral tooth with or without periapical changes. When periap-
ical inflammation is present, biting down on the affected
tooth may be painful; the animal may chew on one side,
avoid hard food or chew toys, be reluctant to bite down on
a training aid, and show increased amounts of calculus on
the affected side.
Radiographs are necessary to confirm endodontic in-
volvement, and the use of dental film and intraoral tech-
nique gives a more detailed image of the root and periapi-
cal area. Excellent technique to allow visualization of each
root without distortion or overlap on adjacent roots allows
accurate diagnosis. In the initial stages of periapical inflam-
mation, there may be no radiographically visible changes,
and confirmation may depend more on clinical evidence of
coronal trauma or discoloration. As the periapical disease
progresses, there is widening of the periodontal space in
the apical region that progresses to a lucent halo with loss
of bony trabecumation around the root end as a granuloma
or abscess forms (Fig. 198-6). Comparison of canal width
with the contralateral tooth also provides evidence of pulp
Figure 198- 6 . Radiogroph of a maxillary founh premolar with evi-
dence of crown damage and periapical Iuccncics at each root.
Endodonttcs 2671
death if the pulp cavity is wider. Radiographs are also a
necessary step in endodontic treatment , starting with a pre-
treatment view as well as during the treatment, and at
regular re-evaluations to confirm success or failure of treat-
ment (Fig. 198- 7).
ENDODONTIC TECHNIQUES
Pulpectomy (Root Canal
Therapy)
The goals of a total pulpectomy, commonly referred to
as root canal treatment, are to remove all pulp tissue and
infected dentin, to shape and disinfect the pulp cavity, and
then to fill the canal completely with an inert material that
seals the canal apically and coronally. This preserves a
nonvital yet functional tooth. Pulpectomy is divided into
three steps: access preparation, cleaning and shaping of the
canal, and obturation or filling of the canal. Restoration of
the access site and fracture site completes the procedure.
Access
Endodontic access in canine teeth has been described. 2. 6 11• 16
Straight-line access to the apex of the tooth either from the
fracture site or through a separate opening created in the
c rown of the tooth is necessary to allow correct shaping
and obturation of the canal. In dogs, with canine teeth that
are intact or have minimal crown fractures, an access open-
ing is made with a small round or pear-shaped burr on the
mesial aspect of the tooth 3 to 5 mm coronal to the
gingival margin. A diamond burr is preferred because there
is greater control and less potential to fracture the enamel.
The burr is initially directed perpendicular to the enamel
and redirected in line with the root canal when the dentin
is entered. A change in sound and feel of the drill is
noticed when the burr enters the pulp chamber. In cats, the
canine teeth are straighter, and a separate access site other
than the fracture site is not necessary.
With fractured incisors and small premolars, the access
can be made directly from the fracture site or directly over
the root canal on the lingual aspect of the tooth near the
cingulum. With maxillary fourth premolars, all three roots
must be treated. Access to the palatal root can be made
through an opening directly over the palatal cusp or by the
transcoronal approach, in which both the palatal root and
mesiobuccal root canals are entered (Fig. 198-8). 2 The
mandibular first molar has two large roots. Access can be
made directly over the distal root in the center of the
occlusal surface and on the lingual aspect of the develop-
mental groove for the mesial root. It may be necessary to
e liminate any !edging in the dentin by using a tapered burr
or Gates-Glidden drill to ensure free movement into the
canal. To enlarge the coronal access area to allow free
movement of the shaft of the endodontic files, a Gates-
Glidden drill is used in sequentially enlarg ing sizes, on a
low-speed handpiece.
Cleaning and Shaping the Canal
A critical step is to determine the working length by
placing a number I0 or 15 file in the canal and gently
2672 Dentistry

Very close to
pulp chamber

Restoration

Radiographic 1• - - - - -- - -- - - - - - - -- - -'
recheck in
3-12 months

Success- Failed Failed

annual root canal direct
rechecks treatment pulp capping

Repeated Apicoectomy- Pulpectomy-

root canal surgical root canal
treatment endodontics treatment

A
Figure 198-7. Overview of the endodontic treatment options for tooth frru:tures (Aj and discolored teeth (JJ).

advancing it apically. This may be to a predetermined
length from the preliminary radiograph or, with a closed
healthy root end, when an apical stop is felt. A confirming
radiograph is taken, and the working length is adjusted as
necessary, m easured, and marked with a small rubber stop
on each file size to be used (Fig. 198-9}. Pulp tissue can
often be removed early in the procedure in larger canals by
inserting a barbed broach into the canal, twisting 360° to
cnsnarl the pulp. and then removing it.
Filing is done sequentially with endodontic files that
come in sizes of 06 to 140 and lengrhs of 21 , 25, 30, 40,
or 60 mm. File size is standardized and determined by the
diameter of the file 16 rnm from the end. There arc three
basic file designs. Hedstrom files have flutes that are cut
perpendicular into the shaft of the file and provide more
cutting and shaping action along the canal walls. They are
used only in a push-pull manner to prevent accidental tip
separation in the canal. K-fi lcs have a close, spiral fiuting
 EndodontiCS 2673

Pulpectomy-
root canal
treatment

Annual radiographic 1+- - - - - - - - 1 Radiographic recheck 1 - - - - -- +1

rechecks in 3-12 months

Apicoectomy-
surgical endodontics
B
Figure 198- 7 Cominued

that is created by twtstmg a solid rod. Reamers have
greater space between the flutes. These files are mostly
used in a push-tum quarter-tum clockwise-pull fashion
and are useful in obtaining the working length and opening
up the apical portion of the canal. They arc more flexible
and less likely to break when used in curved canals. The
design of the flutes allows dentinal filings to be drawn out
of the canal to minimize packing of the apex with debris.
Current alternative file options are in type of metal as well
as a newer file series based on a consistent size increase of
29%, at the tip of the file, between files. A variation is the
ProFile variable taper files· that have a 0.04-rnm or 0.06-
mm increase in width per l mm of file length versus the
standard ISO taper of 0.02 mm per I mm of file length.
Automated techniques of canal preparation include ultra-
sonics, sonics, and engine-driven mechanisms.'
Whichever method of instrumentation is used to clean
the canal, in between file sizes as one is advancing through
the increasing sizes, the previous smaller size file is used
to remove any dentinal debris left behind in the apical
area. This is called recapitulation. Irrigation by use of a
2.6% to 5.25% solution of sodium hypochlorite solution
(household bleach) is done with blunt irrigating needles on
a syringe to provide disinfection and lubrication between
each instrument. 15 Initially to provide lubrication and for a
c helating action of the dentin, an EDTA preparationt is
used on the first three or four file sizes. This he lps to open
up narrow apical canals and to debride this area. When
EDTA preparations arc used throughout the procedure, ex-
cessive dentinal softening may occur. interfering with final
obturation. Each root in multirooted teeth can be filed con-
secutively, adjusting the working length on the file between
each root if there is a difference. The endpoint of fi ling
occurs when the file size is reached at which white dentinal

Fi gure 198- 8 . Endodontic files in place showing the transcoronal ' ProFile Series 29, Tulsa Denial Products, Tulsa, Okla.
accc\\ 10 1he maxillary fourth premolar roo1s as well as a file access s ile 1 RC-Prcp, Medical ProductS Labornlories, Philadelphia, IPa, and Glyde.
direc1ly over lhc palatal cusp (arrow). Maillefer-Denlsply, Tulsa, Okla.
 2674 Dentrstry
Figure 198- 9 . Radiograph wuh m place to detennine working
length.
been seen on several files and the next larger
fi.le stze w1ll not reach the working length. This final file
srzc that reaches working length is noted and detennincs
the size of the master cone.
There are two techniques to shape the canal and create a
slight. funnel shape to facilitate obturation: the step-back
technrque and crown-down technique. The step-back tech-
nique uses increasingly larger files than the master file or
drills that are used at progressively shoner
worlrng lengths to flare the coronal ponion of the canal.
with a small file to working length is done
rn between each file size. The crown-down technique pre-
pares the coronal aspect of the canal with the larger Gates-
Glidden or ProFile variable taper file first. Subsequent
smaller srzes are used to approach the apical portion of the
canal, which is prepared in the traditional manner. After
the canal is shaped, a final irrigation with sterile saline is
perfonncd, and the canal is dried with sterile paper points
that arc in size to the canal. Drying is complete
when the tLp of the paper point remains stiff. The canal is
ready for application of a scaler and obturation.
Obturation
The first step of obturation is to place a sealer in the
fonn of a paste that assists a complete apical seal tills
in small gaps to bind multiple cones of gutta-percha to-
gether, if accessory guna-percha cones are used. The sealer
is bactericidal, is compatible with the periapical tissues,
and well to both the canal wall and the filling
matenal used. 7• 11 There arc several choices in the rype of
sealer. TI1e zinc oxide-eugenol based sealers· and zinc
meet the listed requirements, are biocompa-
llble, and are frequently used in dogs and cats. Other ac-
' Ricl..en's Scaler and Tubli-Seal. Kerr Manufacturing, Romulus. Mich.
ceptable and commonly used scalers are calcium hydroxide
sealers: polymers,t and glass ionomer cements. t The scaler
may come premixed, as a powder and paste, or in capsules
that activated and triturated for mixing. The sealer
paste 1s applied to the inside of a dry canal by a spiral
on a low-speed handpiece with a 10: I reduction gear.
Thts slowly augers the scaler paste into the apical region as
well as lines the sides of the canal. It is not necessary to
fill the entire canal. In nan·ow canals, a file one to two
sizes than the final file size can be used to deposit
sealer mto the canal to the root end by insening it to
and .turning it wise while withdrawing
11. The file IS drawn agam t the canal walls several times to
coat them with the sealer. Sealers set up at various time
intervals, depending on type. The sealer paste is also
placed on the master guua-pcrcha cone as well as acces-
sory points to facilitate placement and complete obturation.
. A number of obturation techniques can be used, dcpcnd-
mg on the size and shape of the canal, equipment avail-
able, familiarity of the operator. With the variability in
canal s1zes and lengths in animals, it is helpful to have
several obturation methods available to select the one or
combination of techniques that gives the best success for
the situation. The obturation material of choice is gutta-
percha. Gutta-percha is a substance made from the latex of
cenain trees that resembles rubber but contains more resin.
It is manufactured into standardized cones that match the
sizes of files as well as accessory points for use in lateral
compaction tec.hniqucs. For veterinary use, 60-mm-long
gutta-percha pomts are available.t These points have a ta-
a.nd parallel sides rather than a continuous taper,
whtch elimmates binding at the neck of the tooth. Guua-
percha is pliable, can be softened by heat or solvents, is
radiopaque, is easily sterilized (by submersion in sodium
hypochlorite), and does not suppon bacterial growth. It is
also unaffected by moisture and can easily be removed
from the canal if necessary. Instruments needed for obtura-
tion are spreaders and pluggers. Spreaders have thin,
pointed metal tips of various widths and lengths and are
placed alongside the master gutta-percha cone inside the
canaL The spreader can also be heated with a flame to
soften the gutta-percha cone and to create space for addi-
tional cones to complete the obturation in wider canals.
Pluggers have blunt-ended metal tips and also come in
various widths and sizes. Pluggers are designed to veni-
cally compact the guua-pcrcha apically. There are two gen-
eral obturation techniques, namely, cold and warm gutta-
percha obturation, with multiple variations in each group.
Cold techniques include single cone, cold lateral compac-
tion, cold vertical compaction. chloropercha, chloroform
dip, and custom point technique/• Warm guua-percha tech-
niques include warm lateral compaction, wann vertical
compaction, McSpadden thermomcchanical, heated syringe,
heated gun, and Thermafil 11 techniques.6 • 16
In narrow canals, a single cone matching the size of the
master file, and with slight resistance or tug-back when it
'ScalapeA, Kerr Manufacruring. M1ch.
' AII26 and AHPtus, CauliJDentsply. Milford. Del.
1Ketac-Endo, ESPE, NorriMown, Pa.
IPar.tllax. Dr. Shipp's Laboratories. Beverly Hills. Calif.
"Tulsa Dental Products. Tulsa, Okla.
 Endodontics 2675

into the canal at working length and, after cooling for a

few seconds, gently twisted counterclockwise and removed,
leaving the gutta-percha in the apical portion of the canal.
A presized plugger is inserted to compact the gutta-percha
apically. This step is repeated until the apical third of the
canal is full, and a radiograph is taken to confirm a com-
plete apical fill. The remainder of the canal is fi lied by the
same process or alternatively with the Ultrafil* cannula, in
which heated gutta-percha is injected into the canal and
compacted apically. Whichever technique is used to obtain
a satisfactory fill, a radiograph is taken to confirm com-
plete obturation of the canal (Fig. 198-11). Gutta-percha
in the pulp chamber is removed with a heated instrument,
and an intermediate filler, such as a type I glass ionomer
or hard-setting calcium hydroxide base,tt is placed over the
canal filling. The access site is prepared for the final resto-
ration of amalgam or composite resin (see Chapter 199).
A minimum of four radiographs are taken during a pul-
pectomy procedure: as a preliminary view and during treat-
ment to confirm working length, master cone placement,
and final obturation. Radiographic rechecks at 3 to 6
months and annually thereafter confirm success or failure
of the pulpectomy procedure. Periapical lesions showing
Figure 198-1 0. Thennafil plastic inserts coated with guua-percha.
After heating in a ThcnnaPrep oven, they are inserted into the prepared
radiographic lucency should have improvement or resolu-
canal. Excess guna-percha is removed. tion of the bony lesion to affirm success of the procedure.
Most pulpectomy procedures can be done as a one-stage
treatment. After filing, there may occasionally be persistent
is withdrawn from the canal, can be placed after the sealer hemorrhage in teeth with bleeding pulp tissue. If the hem-
into the canal and seated apically with a plugger. For root orrhage cannot be stopped by repeated filing to remove all
canals 25 mm or less in length, a single Thermafil cone, pulp tissue remnants, cold saline irrigation, or paper point
presized and heated in a special oven, is placed in the application, a two-stage root canal treatment is necessary.
canal to achieve complete obturation with little additional The canal is medicated with formocresol § by dipping a
manipulation (Fig. 198-1 0). A radiograph is taken to con-
firm complete obturation, the excess gutta-percha is re- 'llygenic, Akron, Ohio.
moved with a heated plugger, and the access opening is tDycal, Caulk/Dentsply, Milford, Del.
prepared for restoration. *Yitrebond, 3MEspe, Norristown, Pa.
•Su ltan Chemists Inc., Englewood, N.J.
More often in animals, the volume, width, and length of
the root canal require additional cones to be placed or
techniques to achieve apical filling in canals that are longer
than 25 mm. 13 This can be done by cold or heated lateral
compaction techniques. After placement of the master cone,
a spreader is inserted along the master cone to compact the
gutta-percha laterally and is rotated back and forth. This
creates a space to place an accessory cone, and the steps
are repeated until the canal is ful l. In young dogs with
wide canals, this can take many additional gutta-percha
points. Alternatively, a spreader can be warmed or an elec-
trically heated spreader• can be used to soften the gutta-
percha, making room for additional points. The disadvan-
tage of this technique can be the inability of most
spreaders to reach the apical limits of the canal in large
canine teeth in dogs, creating the potential for incomplete
fills. 10 Excellent obturation of the root canal of canine teeth
in dogs can be achieved by the Successfil techniquet with
heated gutta-percha in a syringe. 10 A file two or three sizes
smaller than the master file is inserted into the tuberculin
syringe containing the heated gutta-percha. The gutta-per-
cha is slowly extruded onto the file to form a tapered
coating of the thermoplasticized material. The file is placed

'Touch 'n Heat, Analytic Technology, Redmond, Wash. Figure 198- 11. Post-pulpectomy radiograph with complete obturation
1Hygenic. Akron, Ohio. of both roots in a mandibular molar.
2676 Dentistry
paper point into the liquid and insening it in the canal. The
paper point is removed, and a temporary fiUing material is
placed in the access opening, leaving the vapors of the
formocresol to mummify any pulp tissue remnants. In 2 or
3 weeks, the canal can be reopened and the obturation
completed.6 Another indication for a two-stage pulpectomy
is when the apex has undergone inflammatory resorption
and the apical stop is weak or incomplete. A calcium
hydroxide paste is placed in the canal after filing to stimu-
late hard tissue formation. At a later date, the canal is
reopened, the calcium hydroxide paste is removed. and the
canal is irrigated and dried, ready for final obturation.
Complications
Complications can occur at any step of the procedure.
Root perforation from improper angulation or excessive
drilling during coronal access may occur. The root perfora-
tion can be repaired with a calcium hydroxide preparation
placed in the site to stimulate hard tissue repair. Root end
perforation can occur when there is an open apex or by
overaggressive placement of the initial file. Careful meas-
urement of working length helps avoid this complication.
Files, broaches, or reamers may fracture during use and
become lodged in the canal and can be a most frustrating
complication because of the difficulty of removing the sep-
arated tip. A number of techniques may be attempted to
dislodge the obstructing fragment. 17 Improper filing tech-
nique can also Lead to changes in the anatomy of the apical
portion of the canal, such as zipping, !edging, and strip-
ping, which can result in lateral wall perforation.6 • 17
Obturation complications, especially underfiLL of the api-
cal third of the canal, are the most common with total
pulpectomy. This leads to a poor apical seal, percolation of
fluid into the apex, and failure of the procedure. Overfill
by the sealer or overextension of the gmta-percha may also
occur. These cases are observed radiographically to see
whether the periapical tissues react to the overfill materiaL
If persistent periapical reaction and lucency occur, the ca-
nal can be retreated or have a surgical endodontic proce-
dure to resolve the problem. Further crown fracture after
endodontic treatment may occur and may be attributed to
further trauma, weakening of the tooth due to the access.
openings, and a slightly increased brittleness of nonvital
teeth. Tooth discoloration, Loss of restoration, and failure of
periapical changes to resolve are other complications that
may be encountered.
Partial Coronal Pulpectomy
fVital Pulpotomy with Direct
Pulp Capping)
This is the procedure of choice in recent crown fractures
when the traumatic incident is known and the animal is
brought in for treatment within 48 hours for a mature
animal. It is unclear at this stage whether a longer interval
is acceptable in a young animal with incomplete or imma-
ture apices. The goal is to maintain a vital, functional tooth
and to treat the exposed pulp so it will lay down reparative
dentin. A good restoration is important to seal the exposure
site. Partial coronal pulpectomy is also an acceptable treat-
ment option combined with crown amputation for patients
with tmumatic soft tissue injury from maloccluding teeth.
Technique
This procedure is done aseptically with sterile gloves,
instruments, materials, mask and cap, and draping to isolate
the affected teeth. The tooth crown and gingival area are
flushed with antiseptic solution to minimize bacterial con-
tamination, and systemic antibiotics are given preopera-
tively and postoperatively. If the crown is intact, the crown
height is reduced with a diamond burr in a high-speed
handpiece with irrigation. Only much tooth crown is
removed as will eliminate interference with the soft or hard
tissues, to preserve as much functional tooth as possible
and to keep the pulpotomy procedure in the pulp hom for
best results. The pulpotomy is done by use of a diamond
burr in a high-speed handpiece with sterile water irrigation.
The burr size is determined by the size of the pulp hom
and tooth size to create a channel into the pulp chamber
that removes 4 to 6 mm of the coronal pulp tissue. This
provides room for the pulp dressing and the restorative
materials as weU as removes any contaminated pulp. A
diamond burr is preferred because it tears the pulp cleanly
and minimizes pulp trauma. Hemorrhage is controlled by
placing the blunt end of sterile paper points gently against
the pulp stump. Irrigation with cold sterile saline may as-
sist in hemorrhage control. In traumatized teeth, when
bleeding from the pulp amputation does not stop within 5
minutes, an irreversible pulpitis can be suspected and a
total pulpectomy is recommended. In young animals with
an open apex, additional pulp tissue may be removed to
reach less contaminated pulp before aboning the attempt to
maintain a vital tooth to allow root end formation and
additional thickening of the dentinal walL Once hemor-
rhage has stopped, a calcium hydroxide preparation is
placed over the pulp stump. Both hard-setting calcium hy-
droxide base· and straight calcium hydroxide preparations
have been used. The alkaline pH of these products is anti-
bacterial and initiates an inflammatory response in the adja-
cent pulp tissue, which responds by laying down tertiary
dentin to form a dentinal bridge, protecting the pulp whiie
preserving a vital tooth. The calcium hydroxide preparation
is covered with an intermediate filling material, such as a
type 2 glass ionomer, and a final restoration is placed to
seal the exposed dentinal tubules and access opening (Fig.
l9H- 12).
An alternative technique uses a dental adhes.ive. The
tooth is prepared as described before, and a calcium hy-
droxide !inert is provisionally placed over the exposed
pulp. The tooth is acid etched for 20 seconds, and the
etchant is removed and blot dried. A thin layer of dentin
primer is placed on the enamel, dentin, and pulp stump,
followed by a light-cured unfilled resin and a composite
resin res.toration.6
Radiographic follow-up is performed at 3, 6, and 12
'Dycal, Caulk/Dentsply. MiltO..d, Del.
'Hany J. Boswonh Company, Skokie, Ill.

Figure 198- 12. radiograph of a partial coronal pulpec-
tomy wilh radiopaque ca lcium hydroxide, inlermediate filling material,
and final res1ora1ion.
months and annually thereafter to confirm success or fail-
ure of the procedure. The pulp canal continues to narrow
and show no apical changes in the successful procedure in
a young animal with immature roots.
Complications
Teeth treated with a partial coronal pulpectomy that fails
show evidence of pulp death on follow-up radiographs with
no further narrowing of the pulp cavities and possible for-
mation of periapical lesions. If there is an intact apex,
these teeth may be retreated with a total pulpectomy. The
restoration can also be evaluated for loss of integrity and
microleakage.
SURGICAL ENDODONTICS
Surgical endodontics, also called apicoectomy or surgical
root canal , is the procedure whereby the root apex is re-
moved and a retrograde tilling is placed in the apical as-
pect of the canal of a tooth, usually previously treated with
standard root canal procedure. An apicoectomy is indicated
when there is failure of the standard root canaJ treatment
(Fig. 198- 13), a separated instrument precludes adequate
obturation of the apex with standard techniques, or the
canal apex cannot be reached by standard endodontic tech-
nique. The root apex is accessed through a curved incision
in the buccal alveolar mucosa over the root for maxillary
canines, mandibular first molars, and maxillary fourth pre-
molars or through a ventral mandibular approach for the
mandibular canines. A small disc of buccaJ bone is re-
moved over the apex with a diamond burr, allowing an
angled cut of the apex with a tapered cutting burr to
remove the apical 3 to 4 mm of root. A small preparation
is made in the exposed canal to remove gutta-percha, if
present, and to provide mechanical retention for the retro-
grade filling material. Zinc-free amalgam, glass ionomers,
Endodontics 2677
Super-EBA cement, and IRMt have been used as retro-
grade 7 The surgical incision is closed with fine
absorbable sutures.
Endodontic Treatment of
Primary and Immature
Permanent Teeth
Primary Teeth
Primary teeth that become fractured are generally best
treated by extraction because they soon exfoliate. If a frac-
ture is recent, a partial coronal pulpectomy can be per-
formed if it is necessary to preserve the tooth until it
exfoliates as the permanent tooth erupts. However, a frac-
tured primary tooth is not left untreated because this may
lead to periapical infection, which can be painful and may
damage the permanent tooth bud.
Immature Permanent Teeth
Endodontic disease involving a permanent tooth that has
an incomplete apex poses a particular challenge. The thin
dentinal walls of the immature tooth make it more suscep-
tible to injury, and the open apex makes a conventional
root canal procedure difficult. In a recent pulp exposure, a
partial coronal pulpectomy can be performed. If successful,
a partial coronal pulpectomy of an immature tooth allows
the normal development of the root and apex (i.e., apexo-
genesis). The use of the term apexogenesis as a therapeutic
procedure is a misnomer. Apexification is a procedure per-
formed on nonvital immature teeth to stimulate some de-
gree of apexogenesis. Apexification requires removal of the
nonvital pulp and placement of calcium hydroxide in the
entire canal to stimulate closure of the apex with calcified
· oycul, Cuulk/Dcnt>ply, Milford, Del.
11Jcnry J. Boswonh Company. Skokie, Ill.
Figure 198- 13. This tooth was treated with a standard pulpectomy
when there was previous nasal swelling and a periapical lesion. Recur-
rence of the ntl\ul persiMenl periapical lucency. and external
root rc;orption a' vbible on this radiogmph resolved after an apicoec·
tomy.
26 78 Dentistiy
tissue. This allows future standard endodontic treatment
with a solid apical stop. 5
References
I. Anthony JM: Newer endodontic therapeLLtiC tre.1tmcnt. Vet Clin North
Am Small Attim Pract 28: 1237, 199!!.
2. Eisner ER: Transcoronal approach to the palntal root of the maxillary
fourth premolar in the dog. J Vet Dent 7:14, 1990.
3. Emily P: Endodontic diagnosis in dogs. Vet Clin North Am Small
Anim Pract 28: II !!9, 1998.
4. Gorrel C: Radiographic cvalLLati(m, Vet Clin North Am Small Anim
Pract28: J089. 1998.
5. Hennel P: Endodontic treatment ioduding apcxification in a Chow
Chow with a necrotic immature mandibular canine tooth. J \ 1et Dent
15:21,
6. Holmstrom SE, ct al: Endodontics. In Holmstrom SR, et al (cds):
VeierifUiry Dental Technique.v. 2nd ed. W.B Saunders, Philadelphia,
1998, p 257.
7. Lyon KF: Endodontic therapy in the veterinary patient. Vel Clin
North Am Small Anim Prm:l 28:1203, 1998.
8. Manfra Marreua S, et al: Ideal coronal endodontic access poinL' for
the canine dentition. J Ver Dem 10: 12 , 1993.
C H APTE R
199
Restorative Dentistry
Gregg A. DuPont
OPERATIVE DENTISTRY AND
PROSTHODONTICS
Restorative, or operative, dentistry is the art and science
of replacing missing tooth structure with artificial materials.
Restorative materials can reestablish tooth function, restore
esthetics, or do both. Veterinary restorative dentistry gives
priority to reestablishing function. Animals tend to mistreat
their teeth; therefore, any restorative material used must be
strong, be well attached to the tooth, and perform well
with a minimum of mainten!Ulcc.
The two broad categories of dental restorations are direct
placement restorations, which are placed directly into a
tooth defect without any extraoral fabrication, and indirect
placement restorations, such as crowns, inlays, and
onlays. This chapter focuses on direct placement materials.
DIRECT PLACEMENT
RESTORATIONS
Indications
The most common indications for direct placement resto-
rations in veterinary dentistry are listed in Table 199- I.
9. Manfnt Mmerta S, ct al: Classification and prognostic factor!< or
endodontic-periodontic lesions in the dog. J Vet Denr 9:27, 1992.
10. Mendoza KA, et at: Comparison of two heated gutta percha and
sealer obturation techniques in canine teeth of dogs. J Vet Dent 17:
69,2000.
II. Nguyen NT: Obturation of the root canal system. in Cohen S, Bums
RC (eds): Pathways of the Pulp, 5th ed. Mosby- Year Book, St.
Louis, 1991, p 219.
12. P, Verl>eek M: Use or the dental pulp tester in velerinary
dentistry. .1 Vet Dent 14:23, 1997.
13. Rochette J: Identification of the endodontic syst-em in camassial and
canine teeth in the dog . .I Vet Dent 13:35, 1996.
14 . Trowbridge HO, Kim S: PLLlp development, stmcture and function. In
Cohen S, Bums RC (eds): Pathways of the Pulp. 5th ed. Mosby-
Year Book, St. Louis, 1991, p 296.
1:'i. West J 0 , et al: Cleaning and Bhaping the root. canal system. / 11 Cohen
S, Bums RC (eds): Pathways of the Pulp, .5th ed. Mosby- Year Book,
St. Louis, 1991, p 179.
16. Wiggs RB, HB: Basic endoiJontic therapy. In Wiggs RB,
Lobprise HB: Veterinary Dentistry- Principles and Pracrict. Lippin-
cott-Raven, Philadelphia, 1997, p 280.
17. Wiggs RB, Lobprise HB: Advanced endodontic therapies. In Wiggs
RB, Lobprise HB: Veterinary Dentistry-Principles a11d Pracrice.
Lippincou-Raven, Philadelphia, 1997, p 325.
I!!. Wilson Ci: Timing of apical the maxillary canine and
mandibular ftr8t molar teeth of cats. .I Vet Denr 16:19, 1999.
Techniques for Use of Direct
Placement Materials
Endodontic Access Site l?estoration
This is the most common indication for restoration in
veterinary dentistry. The ideal access site is made as small
as required to gain straight-line access to the root canal and
to clean and shape the canal adequately. Any additional
tooth removed beyond this amount further weakens the
tooth without gaining additional benefit.
A number of factors are considered in choosing a restor-
ative material to repair both the fract ure (if present} and
the access opening. Endodontic access site restorations typ-
ically consist of a minimum of two different materials
layered together (Fig. 199-1). A good material choice for
the first layer is a glass ionomer. This avoids the potential
interference of eugenol, a common component of materials
used as sealants during obturation of root canals (see Chap-
ter 198), with polymerization of resins. 16 Also, glass
ionomer bonds to dentin and has a modulus of elasticity
close to that of natural tooth, making it a good choice for
the bulk of the restoration.
Any obturating material is first removed from the walls
of the pulp chamber. The dentin lining the cavity is then
 Restorative Dentistry 2679

"conditioned" with polyacrylic acid, rinsed, and dried bm

not overdried, and the glass ionomer is placed, all accord-
ing to the manufacturer's recommendations. After an initial
5-minute set, the surface restoration is removed to an ap-
proximate depth of 3 mm. A layer of flowable composite
resin is placed over a bonding agent. After 10 to 15 sec-
onds of light initiation, the remainder of the cavity is
slightly overfilled with a hybrid composite resin to extend
to the beveled enamel perimeter. After a full 40- to 50-
second polymerization. it is finished with discs, and a final
layer of bonding agent is placed to seal any margins that D
may have opened from polymerization shrinkage. This
technique bonds the glass ionomer to the inside of the
entire pulp chamber and access preparation to protect
against microleakage, prevents any interference with resin
polymerization that could be caused by eugenol, creates a
long and complete seal against microleakage, uses a flexi-
ble resin buffer between the stiff (high modulus of elastic-
ity) composite resin filling and the more flexible (low mod-
ulus) dentin, then finishes with a surface layer that is hard,
polishable, esthetic, and wear resistant.

Dental Trauma
Even minor tooth fractures that do not involve pulp
exposure often expose dentin. Open dentinal tubules can
result in tooth sensitivity caused by dentinal fluid move-
ment. Exposed dentin also creates a tisk of bacterial in-
gress through the tubules to the pulp. For these reasons,
exposed dentin is sealed with a sealant and possibly re-
stored.
In replacing tooth structure lost from dental trauma, little
or no tooth preparation is necessary other than removal of
any enamel not supported by dentin and beveling of the
enamel margins of the defect (no bevel on root dentin if
the lesion extends subgingivally). 17 The steps arc as fol-
lows: dry the tooth, etch dentin and enamel for 15 seconds,
rinse wen, blot excess water, place the bonding agent, dry,
light activate for I 0 seconds, place a flowable composite
resin, light activate for 10 seconds. place a nonflowable
composite resin to the perimeter of the beveled enamel and
slightly overcontourcd, light initiate for 40 to 50 seconds,
finish with discs to contour and to smooth and polish, rinse
and dry, place a final layer of bonding agent to seal any
margins that may have opened from polymerization shrink-
age.
Pulp Capping
When the pulp has recently been exposed, a direct pulp
capping procedure may be indicated. Whether calcium hy-
droxide or a direct bonding agent is used is discussed in
Table 199-1. Most Common Indications for Direct
Placement Restorations
Endodontic
Replacement of tooth structure by trauma
Repair of enamel defects (dysplasia, hypoplasia)
Caries
External resurptive lesions (selected lesions)
A
Figure 199- I. Restorative layers in typical endodontic access: guna-
percha (A), glass ionomer (B), flowable resin (C), hybrid resin (D).
Chapter 198. Irrespective of the type of pulpal dressing, the
restoration is the same as for other dental traumatic defects.
If a layer of calcium hydroxide is placed, it is important
that this prevents any dentin bonding in that area. There-
fore, minimal use is recommended, and certainly only over
the actual pulp and not extending onto sound dentin. For
indirect pulp capping, in which a thin layer of dentin re-
mains over the pulp, only a bonding agent and composite
resin are used.
Developmental Enamel Defects
Enamel hypoplasia, dysplasia, and hypomineralization
can cause dentin exposure by absent or abnormal enamel
(Fig. 199-2). Exposed dentinal tubules allow entry of bac-
teria with the potential to infect the pulp. Therefore, as a
minimum, teeth with these conditions arc treated with a
dentin sealant. Sealing dentin involves first removing any
calculus. All weak or stained enamel and dentin are then
removed with a small round or pear-shaped burr on a high-
speed handpiece. Next, the surface is acid etched, and a
bonding agent is placed.
To produce a more esthetic surface and to slow the wear
of the exposed dentin, a restoration can be placed over the
bonding agent as described before: place a flowablc com-
posite resin, light activate for 10 seconds, place a nontlow-
able composite resin to the perimeter of the beveled
enamel to form a slightly overcontoured surface, light initi-
ate for 40 to 50 seconds, finish with discs to contour and
to smooth and polish, rinse and dry, place a final layer of
bonding agent to seal any margins that may have opened
from polymerization shrinkage. For this application, the
restorations cover large areas of the tooth bul are relatively
shallow. With this tooth-to-restoration relationship, physio-
2680 Dent•stry
Fi gure 199-2. Enamel hypoplusia before (A) and after (8) restoration
with llowable and hybrid compo'>ite.
logical tooth flexure places large stresses on the bonded
interface between the tooth and the less flexible composite
resin, making the use of a flowable composite resin layer
imponant to prevent adhesive failure or crazing and chip-
ping of the restoration.
Ca ries
Caries results when specific bacteria produce acids and
proteolytic enzymes that attack enamel and then dentin.
Cats rarely suffer from caries. In dogs, although caries is
not a common lesion, it occurs occasionally. Caries in dogs
most commonly affects the occlusal surface of molars. 9
The first step in treating caries is to remove the affected
part of the tooth, differentiated from healthy tooth by being
darker and softer (Fig. 199-3). Most can be removed with
an excavator, followed by a small round or pear-shaped
burr on a high-speed handpiece. Because occlusal surfaces
are subject to heavy loads during use, restoring the defect
requires a wear-resistant but not necessarily esthetically
pleasing material.
Occlusal table (class I) caries on molar teeth can be
restored with amalgam or with a strong composite resin.
With usc of amalgam, undercuts required to provide me-
chanical retention are still needed even when bonding
agents are used because their bond strength to amalgam is
not strong enough for retention of the filling. 20 These un-
Figure 199- 3 . Caries affecting occlusal of a maxillary molar
in a dog. The nffccted po11ion of tooth is easily removed with the
exc:wator.
dcrcuts should be extremely small-almost microscopic-
to be functional without removing excessive sound tooth
substance. A small undercut with a small round burr is
generally adequate; a round burr is better than an angled
burr, such as an invened cone, to prevent sharp angles that
would create a stress riser (Fig. 199- 4). Class I cavity
preparations should not have the enamel margins beveled,
nor should any cavity of any class have beveled enamel
margins when amalgam is used as the restorative (Fig.
199-5). After the defect is shaped, a layer of a dentin-
bonding agent is placed to seal the dentin. The amalgam is
triturated in an amalgamator, then placed and condensed
incrementally into the defect After final compaction, the
restoration is carved to the desired and
later polished.
Resorptive Lesions
Feline odontoclastic resorption lesions are common with
a reponed prevalence of around 50%.Q Altlhough much less
common in dogs, similar resorptive lesions do occur. In
both species, restoration carries a guarded long-term prog-
nosis. The most common lesions occur in the cervical re-
gion of the tooth, where stresses that can contribute to
!
A B
Figure 199- 4 . A, lnvened cone burr creates a sharp angle where
\tre,-;es can be concentr:ued (arrow}. B. A round burr avoid' creatmg
Mress ri'ers.

. ·..
8; ::< .. -;
Figure 199-5. A, Cavity prepar.uion for composite or ionomer
with marginal enamel no other than occlusal B, Cavity prepara-
tion lor amalgam in any site or for any restorative on an occlusal or
dentin surface.
development or ongoing progression of the lesion continue
in spite of restoration. 11 For this reason, resorptive lesions
are rarely restored; affected teeth are often extracted. For
strategic teeth, such as canine teeth, restoration can provide
a functional and comfortable tooth. The client must be
advised that the measure may be only temporary.
The lesion is first debrided of granulation tissue with a
burr. No tooth structure is removed except what is neces-
sary to remove the soft tissue from the resorption lacuna
and to remove any unsupported enamel along the defect
margin. A dentin conditioner (usually polyacrylic acid) is
placed on the dentin according to the manufacturer's direc-
tions. The tooth is rinsed and slightly dried (not desic-
cated), and a glass ionomer is mixed and placed into the
defect, slightly overfilling it. The surface is covered with
varnish or unfilled resin. After 5 minutes, the restoration is
finished with finishing burrs or finishing discs. Another
coat of varnish or unfilled resin is placed immediately after
finishing.
Direct Placement Restorative
Materials
The use of dental restorative materials is changing rap-
idly because of advances in materials technology and the
introduction of new products. Keeping up with these new
materials may seem overwhelming; a recent dental supply
catalogue· lists almost 70 different products with more than
900 different order numbers (shades, accessories, kits) un-
der the listing of "Composites and Restoratives." However,
there are only a few simple classes of materials used for
direct placement restorations. Many of the clinical and
working properties of these materials are characteristic of
their class. Therefore, a brief overview of each class is
appropriate. The standard for restorative materials with the
longest clinical success is dental amalgam. Newer materials
·su!livan-Schein: nental Catalog. Fall/Winter 2000.
Restorative Dentist/)' Z681
are composites, glass ionomers, or some mixture of com-
posite and glass ionomer.
Dental Alloys
Although some new dental composites are hard and
strong, dental alloys remain the hardest materials available
today for direct placement restorations. 1J Amalgam is the
most common and most successful alloy used and contin-
ues to exhibit the best long-term results."' It is easy to use,
helps maintain a seal against leakage by developing corro-
sion at the amalgam-tooth interface, and has withstood the
test of time. Use of amalgam in humans has become con-
troversial in the public opinion because of concerns about
its mercury content and therefore its potential health haz-
ard. As in many controversies, opposing views vary widely
and are argued passionately by their proponents. A poor
esthetic result is another reason for a decline in amalgam
use; it does not match natural tooth structure and can
darken over time as it corrodes. An additional disadvantage
is that because amalgam does not bond to tooth structure,
more tooth must be removed in preparing a cavity to re-
ceive an amalgam filling to create an undercut for mechan-
ical retention.
New alloys have been introduced in an attempt to find a
hard material without mercury. One alloy that is somewhat
promising is gallium, although it is more technique sensi-
tive than amalgam and can exhibit unacceptable expan-
sion-particularly if there is any water contamination dur-
ing placement. 15
Glass lonomers
Glass ionomers are supplied as two separate materials
that are mixed together. The dry component is usually an
acid-soluble calcium fluoroalumino-silicate glass powder,
and the liquid component is usually an aqueous solution of
polyacrylic acid or a copolymer of polyacrylic acid with
other acids. 3 In a few formulations, the manufacturer in-
cludes the acid in a freeze-dried form with the powder
phase, supplying water as the liquid to activate the acid.
When the powder and liquid are combined, the surfaces of
the glass particles are attacked by the acid. The polyacrylic
acid chains are cross-linked by calcium ions to form a
solid mass. The initial set occurs in about 5 minutes, after
which the material can be finished. However, a more com-
plete set continues for 24 hours, during which the material
must be protected from desiccation or moisture contamina-
tion. This is accomplished by placing a layer of unfilled
resin or varnish immediately after insertion of the material
and again after any finishing.
The mixture ratio of powder to liquid is important and
must be measured precisely. Some glass ionomer systems
eliminate this difficulty by providing the materials in cap-
sules with premeasured amounts of liquid and powder.*
Activation of the capsule breaks a septum and combines
the two materials, after which it is placed in an amalgama-
tor tor mixing. An injector device then delivers the mixed
glass ionomer into the defect (Fig. 199-6). The freshly
"Ketac-Fil Aplicap and Ketac-Molar Aplicap. ESPE, Norristown, Pa.
2682 Dentistry
Figure 199-6. Glass ionomer being delivered into an endodontic ac-
cess site. Note the glass ionomer filling the pulp chamber and exiting the
tip where the tooth was fractured.
prepared tooth surface is acid etched-commonly with an
acrylic acid conditioner- then rinsed well. It should be
dried but not overdried, not wet but not desiccated. The
glass ionomer is immediately placed and covered with a
varnish. If the glass ionomer becomes dull before place-
ment, the surface acid has already reacted and the ability to
bond to tooth structure has been lost. After an initial set of
at least 5 minutes, it is shaped with finishing burrs or
discs. After final finishing, another layer of varnish or un-
filled resin is applied to the surface.
The greatest advantage of glass ionomer is its ability to
bond inherently to tooth structure. Therefore, it does nol
require the use of a bonding agent. The fact that ftuoride
ions are leached from the surface and may exert a local
cariostatic effect, possibly protecting against recurrent car-
ies, may be advantageous for use in humans. The main
disadvantages of glass ionomer are the higher wear rate,
greater susceptibility to abrasion, poorer polishability, and
less resistance to fracture compared with composites.
Composite Resins
Composite resin restorative materials are a composite of
two distinctly different materials that have been combined
to take advantage of the strong qualities of each. The
mixture is generally a dimethacrylate or dimethyl methac-
rylate monomer, which forms the matrix when it polymer-
izes, and an inorganic filler that is incorporated into the
mass. 2 If the filler particles are well bonded to the matrix,
they significantly increase the strength of the material both
for fracture toughness and against wear and abrasion. The
earliest resins had no filler particles and wore down
quickly. Large particles were then added, which made it
hard but resulted in a rough surface that would not polish
well. As matrix wore away between the large hard parti-
cles, the surface also became more rough with time. Micro-
fils· with tiny particles were then used to create a highly
"Silux Plus Anterior Restor.ttive, 3M. St. Paul, Minn; Rename!, Cosme-
dent, Chicago. Til.
polishable surface. The now popular hybrid• and micro-
hybrid materials include large, small, and tiny particles to
obtain strength, wear resistance, and polishability.
Composite materials need an initiator to start the poly-
merization reaction. There are two main categories of com-
posite resins, autoinitiated (autoactivated) and light initiated
(light activated). The autoinitiated composites are supplied
in two separate containers that are mixed together. The
mixing creates free radicals that initiate polymerization.
Light-initiated composites require a light activation unit to
begin the reaction. Although expensive plasma arc and
laser units are available, there is no compelling evidence
that they are clinically superior to a good-quality but much
cheaper halogen unit. In fact, some do not fully cure cer-
tain resins.t The unit should be capable of generating light
of an intensity of at least 600 mW/cm 2 • Light gun output is
tested regularly with a radiometer; the efficiency of lights
diminishes with time because of contamination of the cur-
ing tip, degeneration of the filament, and changes in the
transmitting ability of the light guide.
T he greatest disadvantage of composite resins is their
tendency to shrink when they polymerize. When the restor-
ative shrinks, stresses are placed on the bonded interface.
This can result in gaps between the restoration and the
dentin and open margins with resultant microleakage.
Polymerization shrinkage can be minimized by placing rel-
atively small increments and initiating the cure between
increments. Currently, polymerization initiation techniques
are being investigated to prevent the shrinkage problem;
some new light units ("curing guns") allow the operator to
choose between ramp, pulse, or step-up technique. Ramp
initiation starts with low light intensity that slowly in-
creases to full power. Pulse initiation cures for a short
time, then a longer time, and finally finishes with a full 40-
to 50-second cure. Step-up technique starts with a low
intensity then steps up to progressively higher intensity
levels. These techniques are an attempt to slow the rate at
which the stress of shrinkage is applied to the bonded
surface, thereby relieving stress forces to prevent strain.
New Subcategories of Composites
Although composites have been available for more than
40 years, some advances are noteworthy. One of these is
the development of materials with better wear and fracture
toughness characteristics that are sometimes called poste-
rior composites because of their ability to withstand heavy
forces on occlusal surfaces of posterior teeth. 10· 13 Another
introduction is composites that are flowable.t4 These low-
viscosity materials can be injected into a defect. Their main
advantage is their lower modulus of elasticity, making
them more flexible - similar to the flexibility of natural
dentin. When used as a "sandwich" layer between the tooth
and the higher modulus but tougher, higher tilled compos-
ite materials, the flowable composite resin acts as a buffer
to distribute stresses as the tooth bends, thereby taking this
' Herculite XRV, Kerr, Orange, Calif; Prodigy, Kerr, Orange. Calif;
Filtek Z250 Restorative, 3M, St. Paul, Minn.
' Clinical Research Associates: Newslel/er 24:3, 2000.
!Revolution. Kerr, Orange. Calif; Flow-It, Jeneric, Wallingford, Conn;
AeliteFio, Bisco. Itasca, Ill.

stres:s from the adhesive interface.22 F1owable resins also
reduce microleakage when used as a liner before placement
of higher filled compositcs.21 A third subcategory includes
the condensable or packable composites! These use differ-
ent filler materials to allow operators to them with the
same techniques and feel with which they are familiar
through the usc of amalgam. The materia! is placed and
compacted like amalgarn. 14
Mixtures of Composites with Glass
ronomers
Resin-modified glass ionomers and poly-acid-modifie.d
resins (compomers) are mixtures of glass ionomer with
composite resin in an effort to attain the good qualities of
each in a single material. Unfortunately, they also share
their weaknesses as well. 5• 8 For example, resin-modified
glass ionomers (mostly glass ionomer with some resin)
allow light activation for a faster initial set and have supe-
rior fracture resistance because of the resin component.
However, their inherent bond strength to dentin is weaker
because of less glass ionomer, and they are subject to
weakening from water absorption effects similar to glass
ionomcr. 7 In contrast, compomers (mostly composite resin
with some glass ionomer) retain almost no inherent bond-
ing ability and must be placed with a bonding agent just
like the pure resins. Tn general, in veterinary dentistry, it
may be best to use straight glass ionomers and straight
composite resins when indicated.
Dentin-Bonding Agents
Enamel bonding by acid etch techniques to develop a
micromechanical bond is routine. Bonding to dentin in
addition to enamel is necessary with modem restorative
materials to prevent microleakage and adhesive failure and
to allow ultraconservative cavity preparation without a
need for mechanical undercuts that remove healthy tooth
structure. The dentin bond is achieved with most modem
materials through the use of hydrophilic resins that form
resin tags into open dentinal tubules and also form a layer
of hybridization as they displace the water entrapped in the
suspended network of collagen fibers of etched dentin. Af-
ter polymerization, the superficial layer of the resin remains
unpolymerized because of air inhibit1on, providing a sur-
face to which the restorative material can bond.
Indications. Composite resins can effectively be bonded
to enamel and to dentin with a dentin-bonding system.
Acid-modified resins (composite with some glass ionomer
mixed in) do not acquire enough of the glass ionomer's
inherent bonding ability because of the small amount of
glass ionomer. They therefore also require the use of a
bonding agent similar to that needed by composites. Glass
ionomers do not require a bonding agent because of their
inherent ability to bond to dental surfaces. Resin-modified
glass ionomers also do not require a bonding agent because
they retain enough of the glass ionomer's inherent bonding
ability owing to their relatively high content of glass io-
nomer. However, their bond strengths are often lower than
'Pyn1mid, Bisco, Itasca, Ill; P60, 3M, St. Paul, Minn.
Restorative Dentistry 2683
those of straight glass ionomers. The strength of any of
these bonds to enamel is stronger than to dentin. However,
with current bonding agents, a bond to dentin is strong
enough to hold the restoration in position without the need
to remove more tooth for mechanical retention. A layer of
bonding agent is also placed under amalgam restorations to
seal the dentin. The bond strength is not sufficient to hold
an amalgam restorative in position, so undercuts are still
required. 19 Ideally, a dual-cure material (cure is initiated by
both light activation and chemical activation) can be used
for this because the light gun cannot penetrate the amal-
gam. However, a light-initiated material that is cured be-
fore the amalgam is placed is also acceptable because the
main function of the bonding agent is as a sealant, not for
retention of the amalgam.
Procedure. For most currently available products, multi-
ple steps are required even in one-component systems. Af-
ter the cavity has been prepared and shaped, it is dried and
acid etched. Many acids can etch dentin, but phosphoric
acid is best for enamel. Tn general, enamel is etched for a
minimum of 15 seconds, but dentin is etched for a maxi-
mum of 15 seconds. Therefore, when a combined etch
technique is used, etch for 15 seconds. The tooth is rinsed
well to remove the acid and the minerals and by-products
of demineralization, and it is kept moist between etching
and placement of the bonding agent. Modem bonding sys-
tems usc "wet-bonding" techniques. Keeping the dentin
moist is vital to achieve maximal bond strength. If the
dentin is de.<;iccated. the demineralized collagen fibers col-
lapse into an impenneable mass that cannot be penetrated
by the resin, preventing form ation of the hybridization
layer and preventing the resin from flowing into the den-
tinal tubules. 12 If the dentin is accidentally desiccated, wet-
ting with water for a minute restores the collagen's open
structure and allows the resin to replace water and to form
a hybridization layer.
Although the procedure for applying most modem bond-
ing agents is similar, one should follow the directions for
each specific material because there are some differences.
The key points are to etch for 15 seconds, rinse well
(except self-etching products), blot pooling water but do
not dry the Looth surface (all fourth- and fifth-generation
products), apply the product and dry well before light initi-
ation, then apply the restoration before any surface contam-
ination can occur.
INDIRECT PlACEMENT
RESTORATIONS: FULL<ROWN
COVERAGE
Indications
Indirect restorations include inlays, onlays, partial-cover-
age crowns, and full-coverage crowns. The most common
indirect restoration in veterinary use is full-coverage crown
restoration. It is most often used to restore coronal tooth
slructure that requires building up of additional crown size
or shape to reestablish function of the tooth and health of
the periodontal tissues. Many fractured teeth do not require
this step because the function and periodontal health re-
2684 Dentistry

ILoss of crown
substance

I
t
I Nontraumatic I ITraumatic I
I
t l_
I I I I I
TI
Developmental Endodontic Resorption
enamel defect procedure lesion

Etch and seal,

or bonding agent,
flowable resin,
Glass ionomer to
fill pulp chamber,
cover with resin
Bonding agent and
posterior resin or
Glass ionomer
(rarely restored)
I
amalgam
and hybrid resin (layer of llowable
on surface resin optional)

Loss of function,
crown integrity, or
No loss of function, coronal anatomy with
crown integrity, or adverse effects on
coronal anatomy periodontal health

I
J t
Fence-biting
lesions
I I No pulp
exposure
I Recent pulp
exposure in
Pulp exposure in
adult animal or
young animal pulp exposure of

I I
unknown duration

I t
I
+- t t
Behavior can be modified
Nonworking dog
Ongoing behavior
Working dog
Dentin sealant
or bonded resi n
I Endodontic treatment
(Chapter 198)
I Endodontic
treatment if
Strong tooth Weakened tooth indicated
(Chapter 198)
I
J
l No treatment
or dentin sealant
I
Full-crown
coverage

Figure 199- 7. Algorithm for choice or material and cavity prepararion.

main intact with endodontic treatment and mild odonto-
plasty ro smooth the tooth (Fig. 199-7).
Canine teeth may benefit from a crown to regain lost
length for working dogs. Intact maxillary fourth premolar
teeth have a bulge on the midbuccal surface that protects
the gingiva during mastication. When this tooth suffers a
buccal s lab fracture large enough to convert this s utface to
a concave shape, the tack. of a natural buccal bulge predis-
poses the gingiva to masticatory trauma and secondary
periodontal disease. The remaining tooth is also weaker
because of loss of width, with an associated increased risk
of further fracture during normal use. In this case, a crown
is placed to reestablish the cervical architecture and to
protect the covered part of the tooth.
A third indication for a crown is to protect a canine
tooth from trauma caused by hannful chewing habits. A
common lesion occurs on the distal s urface of canine teeth
when dogs bite fences or cage doors. The distal surface
wears away from the abrasion, resulting in a concave cur-
vature and a weakened tooth that is predisposed to fracture
(Fig. 199-8). The best treatment for this (in addition to
behavior modification) is full-crown coverage to slow the
wearing of lhe teeth and to provide strength to the clinical
crown. A three-quarter onlay can also be used, but full-
crown coverage provides greater retention and protection.
Materials
The most commonly used materials for crowns on dogs
are nickel-chromium alloy and gold alloy. Dogs rarely de-
velop nickel allergy, and the nicke l-chromium provides one
 Restorative Dentistry 2685

of the hardest materials available. Gold is preferred for

human use because it is softer and therefore allows the
operator to burnish the margins; it also has a relatively
hypoallergenic nature. Dental gold alloys can also be used
for dogs and cats. It is recommended to have the bonded
surface of gold crowns zinc plated before cementation to
improve the gold-luting agent bond strength. Porcelain
fused to metal provides an esthetic material that can look
like natural tooth structure, but it is likely to chip with use.
Full ceramic crowns are not as strong as nickel-chromium
and require more tooth reduction to compensate for a
thicker crown, resulting in more weakening of natural tooth
structure.

Procedure
The tooth must be prepared to receive a crown by shap-
ing and sometimes reduction for occlusion. The ideal shape
of a prepared tooth for maximal retention would have all
sides exactly parallel. This would be too difficult to create,
and it would be difficult for the laboratory to make an
accurate wax model for casting the crown. Therefore, the
preferred tooth shape has all the sides slightly off parallel
with each side approximately 4° convergent toward the top
of the tooth (Fig. 199-9). The least amount of tooth is
removed that allows elimination of all undercuts. This
sometimes translates into almost no tooth reduction at all.
There are a few options for margin preparation.
For minimal tooth preparation, a feathered edge crown
margin can be requested. A preferred margin is a chamfer
margin, to guide the laboratory technician on exact margin
placement and to provide a solid rest for the crown during Figure 199-9. A. Can ine tooth prepared to receive a crown. B. Crown
in place.
mastication. For periodontal health, the margin is placed at
least I mm supragingivally whenever possible... 18 How-
ever, it is sometimes necessary to place a buccal margin
(e.g., maxillary fourth premolar teeth) in the gingival sul- purpose of mechanical protection of the gingiva. For max-
cus.3 This compromises the sulcular environment for the illary fourth premolar crowns, it is recommended to leave
the palatal cusp uncovered. lf the palatal cusp is included
under a crown, it must first be reduced to allow occlusion,
which weakens the tooth, and its inclusion provides essen-
tially no additional retention.
When the tooth has been shaped as desired, a detailed
impression is obtained with either a polyvinyl siloxane or a
polyether-elastomeric impression material. Full-mouth im-
pressions are made with alginate, and study models in
dental stone are immediately made. These stone models
and the detail impressions are sent to a dental laboratory.
The laboratory technician makes a wax model of the
crown, then casts it in metal and returns the polished
crown to the veterinarian for seating and cementation. A
strong luting agent is used, such as a composite cement:
to cement the crown.

THE FUTURE OF DENTAL

RESTORATION
Restorative materials have undergone a transformation
from "filling" materials to true restorative materials. The

Figure 199-8. Cage-biting lesions on the distal surface of canine 'C & B Metabond. Parkell. Fanningdale. N.Y.: Panavia-21. J. Morita,
teeth. Tustin , Calif.
2686 Dentistty
ideal restorative material would exactly match the structure
of the lost portion of tooth. For example, dentin would be
replaced with a material that includes tubules that would
allow fluid movement and extension of pulp components,
covered by an iTiorganic artificial enamel made with a crys-
talline rod hydroxyapatite structure. These mate1ials have
yet to be made. The be.st replacement for tooth structure
would seem to be tooth structure; if enamel is lost, we may
one day be able to replace it with human enamel. For a
deeper lesion, replacement with dentin-supporting material
under enamel prisms, with structure that would allow com-
munication with the pulp chamber if indicated, would be
ideal. With the completion of the Human Genome Project,
more possibilities may arise for developing the ideal dental
restorative material. Some investigators are already working
on cloning dentin and enamel. Already there are materials
being used for indirect restorations that incorporate fluoro-
apatite-leucite glass ceramic to mimic the crystal structure
of enamel for a more natural light dispersion: With ad-
vances in technology continuing at a fast rate, along with
the desire for better products by both manufacturers and
consumers, there is no reason to believe that this field will
slow in its phenomenal rate of change and improvement.
References
1. Ackerman MB: The full coverage restoration in relation to the gingi-
val sulcus. Compcnd Conlin £due Dent 18: 11 31, 1997.
2. Anusavicc KJ: Philips" Sc:ienu of Dental MmeriaLf, lOth ed. WB
Saunders, Philadelphia, 1996.
3. Baum L, et al: TeAtbuuk of Operative Denrisrry. WB Saunders, Pltila-
delphia, 1995.
"d. SIGN , Iv oclar North America, Inc., Amhen<t, N.Y.
C H A P T E R
200
Orthodontics
Philippe Hennet
Orthodontics is concerned with the diagnosis, guidance,
and correction of growing and mature dentofacial struc-
tures, including conditions that require movement of teeth,
and correction of malocclusions and malformations of re-
lated structures by adjustment of relationships between
teeth and facial bones by the application of forces or the
stimulation an d redirection of the functional forces within
the craniofacial complex. 1
4. Bayne SC, e1 a!: A chara.cteriz.ation of first-generation flowahle com-
posites. J Am Dem Assm: 129:561, 1998.
5. Brackett WW. eta!: !-Year d inical evaluation of Compo-Giass and
Fuji II LC in cervical erosionjabfrolction lesions. Am 1 Denr 12:119,
1999.
6. Burke FJ, et al: Restoration longevity and analysis of reasons for the
placement and replacemem of restorations provided by vocati•)nal
dental practitioners and their trainers in the United Kingdom.
Jenu lnt 30:234. 1999.
7. Cauani-lArente MA, et al: Effect of water on the ph ysical properties
of resin-modified ionomer cements. Dent Mater 15:71, 1999.
8. Christensen GJ: Compomers vs ionomers. 1 Am
Denr Assoc 128:479, 1997.
9. Harvey CE, Emily PP: Small Animal Denlisrry. Moshy, St.
1993.
10. Jackson RD, M: The new posterior resins and a simplified
placement technique. JAm Dent llssoc 131:375, 2000.
11. K uroe T, et al: Biomechanics of' cervil.:al tooth structure and
their Quinte.1senc:e Tnt 31:267. 2000.
12. Latta MA, BarkmeieT WW: .Dentlll in contemporary restora-
tive dentistry. Dent Clin North Am 42:567, !99R.
13. Leinfeldcr KF: Posterior composites, state-of-the-art clinical applica-
tions. !)em Clin North Am 3 7:41 ! , 1993.
14. Leinfcldet- KF, et al: A report on a new condensable composite for
the restoration of posterior teeth. Compend Conlin F.duc Dent 129:
567, 1998.
15. Nea J, et a!: Clinical evaluation and microstructural analysis of a
direct placement gallium restorative alloy. J Dt:nt 28:123, 2000.
16. O'Brien WJ : Denral Marerials and Their Selection, 2nd ed. Quintes-
sence Publishing, Chicago, 1997.
17. Owens BM, et al: Microleakage \)f tooth-colored restorations with a
beveled gingival margin. Quinus.wu:e lnr 29:356, 1998.
18. Page L, Halpern BG: Restorative dentistry, intcracti\tnS with perio·
dontics. Denr Clin Norrh Am 37:457, 1993.
19. P(1l!oni S, Pedrazz.i V: The bonded amalgam restoration. Qui11tessence
lnt 29:171, '1998.
20. Staninec MA, Holt M: Bonding of amalgam to tooth structure: Ten-
sile adhesion Md microleakage 1 Prmthn Dent 59:387. 1988.
2 1. Tung FP, et al: Microleakage of a resin composite: An
in vitro investigation. Quintessence lnt 3/:430, 2000.
22. Unterbrink GL, Liebcnberg WB: Flowable resin composites as "filled
adhesives": LiteratUTe review and clinical reconuncndations. Quintes-
sence lnt 30:249, 1999.
TERMINOLOGY
Related to Jaws
Abnonnal jaw length is described as prognathism when
a forward relationship of one jaw relative to the other jaw
is present. Retrognarhism describes a condition in which
one jaw is caudal to iLs natural relationship with the other
 Orthodontics 2687

of a mandibular premolar occluding distally with its maxil-

lary counterpart can be described as distoclusion.

NORMAL OCCLUSION
Head Shapes
Dogs and cats may be classified into three categories,
depending on their head shape: ( I) mesaticephalic: dogs

t UNGUAL
PALATAL
w ith medium length and width muzzle (e.g., spaniel, bea-
g le, retriever); (2) dolichocephalic: dogs with long and nar-
row muzzle (e.g., collie, greyhound, dachshund); and (3)
brachycephalic: dogs with short and wide muzzle (e.g.,
LABIAL OR BUCCAL boxer, bulldog, pug).
In the first lwo categories, dogs have a synchronous jaw
length with a scissors bite incisor occlusion, that is, the
maxillary incisors are labial (rostral) to the mandibular
o nes and slightly overlap them. In the last category, ani-
mals have a shorter upper jaw as a result of abnonnal
development of the bones of the basicranial axis. As a
consequence, most brachycephalic breeds have retrognathic
occlusion, that is, the maxillary incisors occlude lingually
<D MESIAL
(caudally) to the mandibular incisors (reverse scissors bite).
® DISTAL
® PALATAL Some brachycephalic breeds have a scissors bite occlusion
@ BUCCAL (e.g., cavalier King Charles spaniel) because the mandible
® LABIAL is bowed ventrally, which decreases the jaw length discrep-
ancy between the maxilla and the mandible.

Tooth Position
Nonnal occlusion in a mesaticephalic dog is character-
ized, in the sagittal plane, by an incisor scissors bite, a
Figure 2 00- 1. Tenninology for indicating displacement or position of mandibular canine evenly spaced between the maxillary
the teeth in relation to the dental arches. third incisor and the maxillary canine, and a regular inter-
digitation between maxillary and mandibular premolars,
that is, the cusps of mandibular premolars are p laced in the
jaw. Adding the adjective " maxillary" or "mandibular" to
interdental space of the two opposite maxillary premolars
these two tenns describes the conditions more precisely.
(Fig. 200 -2). In the transverse plane, the mandibular first
The tenn bracllygnathism is often used instead of retro-
molar occludes along the palatal surface of the maxillary
gnathism. However, the scientific meaning is slightly dif-
fourth premolar. In the vertical plane, the c usps of the
ferent because brachygnathism indicates that the jaw is
mandibular incisors occlude against the cingula of their
shorter. maxi llary counterparts, and the maxillary and mandibular
premolars show interdigitation.
Related to Teeth
Position of the teeth is frequently given in relation to the
dental arches. ln the sagittal plane, the prefixes used are
mesio-, labio-, bucco- or vestibula-, palato-, and
linguo- (Fig. In the l'ertica/ plane, infra- and
supra- are used. These prefixes arc associated to the tenn
describing the position or the displacement of the teeth:
-position, -version (describing tipping of the tooth); -rota-
tion, -elusion (describing the occlusal relationship of a
tooth to its counterpart). For example, an incisor that is not
fully erupted and docs not have the nonnal occlusal rela-
tionship with its counterpart is in infraclusion. The dis-
placement of a maxillary canine that is tipped forward
(mesially} can be described as a mcsioversion. The position Fi gure 200- 2 . Nonnal occl usion in a mesaticephalic dog.
2688 Dentistry
MALOCCLUSIONS
Causes of Malocclusion
Malocclusions may result from malposition of teeth
(dental malocclusion), jaw size discrepancy (skeletal maloc-
clusion). or a combination of both. Jaw length, tooth bud
position, and tooth size arc inherited and independently
regulated genetically. 18 The maxilla and mandible arc also
independently regulated, explaining the diversity of jaw
sizes that occurs in different breeds. In humans, malocclu-
sion is partly the result of hereditary factors, whereas den-
tal malocclusion is under the greater control of environ-
mental factors. 5 This could be extrapolated to dogs and
cats.
Specific genetic mechanisms regulating malocclusions
are unknown, but a polygenic mechanism is most likely
involved. With a polygenic mechanism, the severity of
clinical signs is linked to the number of defective poly-
gens. At least 50% of all malocclusions may be acquired
17
and have no genetic There are no data to sub-
stantiate such a claim in dogs or cats. Persistent deciduous
teeth may be the cause of malocclusion. Persistence of
deciduous teeth itself is likely to be genetically influenced
in toy- and smaJI-hreed dogs.
Ethical Considerations
Medical (predisposition to periodontal diseac;e), func-
tional (alteration of mastication or speech), and psychologi-
cal (alteration of cosmetic appearance) problems related to
malocclusion are primary reasons for treatment in humans.
Orthodontic correction for cosmetic reasons in show dogs
raises ethical concerns. Correcting an inherited dental ab-
normality to give the animal an appearance in agreement
with the standard for the breed is considered unethical by
the American Veterinary Medical Association and is a
cause for disqualification by the American Kennel Club.9
However, practitioners in favor of orthodontics may claim
that it is not wise to eliminate from reproduction all dogs
with malocclusion because they may also carry overall
good genetic qualities, which could be of value for lhe
breed.
There are no unanimously accepted rules; however, it is
important for individual practitioners to have justifiable
guidelines fur treatment. For example, the policy at the
University of Cali fornia at Davis on orthodontic correction
is as follows .. :
I. Orthodontic treatment is performed only if the maloc-
clusion causes pain and discomfort to the patient and if the
patient will (medically) benefit from the treatment.
2. Orthodontic treatment is performed only if the advan-
tages of the planned treatment outweigh the disadvantages
(e.g.. repeated anesthesia, discomfort associated with the
appliance).
3. The possible genetic background is emphasized to the
client, and neutering of the patient is recommended but not
required.
4. The privacy of the client is maintained.
'Frank J. M. Verstraete, University of Califomiu. Davis, personal c.:om-
munication. 200 I.
With a skeletal malocclusion, if treatment is necessary
for the welfare of the animal. a nonconservative treatment
(e.g., crown height redm:tion for linguoverted mandihular
canines) and neutering are recommended.
DIAGNOSTIC APPROACH TO
MALOCCLUSION
Most m1hodontic prohlems are encountered in dogs that
are supposed to have a normal incisor scissors bite; they
may be mesaticephalic, dolichocephalic, or sometimes
brachycephalic (e.g., cavalier King Charles spaniel). The
first step is to determine whether the malocclusion has a
skeletal component.
Sagittal Malocclusion
Rostral (Anterior} Crossbite and Edge-
to-Edge Incisor Relationship
Rostral (anterior) crossbit.c is commonly used to name a
condition in which the maxillary incisors occlude lingual1y
(caudally) to the mandibular ones (reverse scissors bite).
This may be a dental malocclusion, if only the incisors arc
affected. However, if it is a skeletal malocclusion (maxil-
lary retrognathism or mandibular prognathism), not only
the incisors but also the premolars have an abnonnal occlu-
sion (distoclusion of maxillary premolars, mesioclusion of
mandibular premolars). A diagnostic approach to this con-
dition has been proposed (Fig. 200- 3). 10
Rostroversion of Maxillary Canine
Teeth
This condition, commonly known as lance canine or
spear teeth, has been identified in different breeds. It may
be seen in toy or small dogs as a consequence of persistent
deciduous canine teeth. It has been recognized with a hreed
predisposition in Shetland sheepdogs.
Mesioclusion and Distoclusion of
Premolars
In most cases, premolar malocclusions in the sagittal
plane are associated with malocclusion of the incisors. A
mesioclusion or a distoclusion of premolars can sometimes
be associated with a normal incisor scissors bite. The adap-
tive growth of the jaws enables them to keep a nonnal
inc isor occlus ion by catching up a slight jaw length dis-
crepancy by different mechanisms (e.g., bowing of a part
of the jaw, inclination of the teeth).
Transverse Malocclusion
Base-Narrow Canines
This malocclusion may be due to a skeletal abnormality
(micrognathia, narrow mandible) or to a dental abnonnality
(linguoversion of the canines). Persistent deciduous canines
may the latter.
 Orrhodontics 2689

PREMOLAR - MOLAR
OCCLUSION

r- ·--
l l;
I Normal premolar -
molar occlusion ary premolars
Crowding of maxillary
premolars

I
L ___ -·· I SKELETAL
MALOCCLUSION
..

CANINE OCCLUSION
Mandibular canine
closer to maxillary third
r-- Underdeveloped _ _j
Jnclsor than to maxillary premaxilla
c;anine
I
- I
!

' Palatoversion of all

I
I I'IWXillary Incisors or I
I miDdlary third Incisors
only

elusion

Palatoversion of
DENTAL
mmdllary first and/or
MALOCCLUSION
second incisors

I
·-··--·-

Vestibuloverslon of
mandibulllf incisors

Figure 2 00- 3. approacll to rostral (anterior) crossbite.

Caudal (Posterior) Crossbite
This condition is seen in dolichocephalic dogs with a
narrow maxilla. The maxillary four1b premolar occludes
lingually to the mandibular first molars.
jaws. These are skeletal malocclusions of genetic or trau-
matic origin. Wry bite may be associated with an inability
to bring the incisors in occlusal contact, a so-called open
bite.

Other Malocclusions Toot h Rotation and Cr owding

individual teeth may be rotated across their long axis.
Wty Bite Rotation of premolars is an indication of jaw shortening.
Wry bite is a descriptive term used for a variety of Incisors may be rotated or displaced rostrally or caudally in
malocclusion syndromes characterized by asynunetry of the case of crowding.
2690 Denristry
BIOLOGICAL BASIS OF
The tooth is anchored to the alveolar bone by the peri-
odontal ligament, which acts as a shock ahsorber. Physio -
logical forces continuously exerted on teeth (occlusion,
tongue, lips, and cheek muscles) are in equilibrium; they
do not induce tooth movement but contribute to bone and
periodontal ligament remodeling. During mastication, heavy
forces may be developed. After 3 to 5 minutes of pressure,
periodontal ligament fluid is squee7.ed out, the tissues are
compressed, and pain is felt. This physiological response
during normal function result<; in the release of the pressure
applied on the teeth.
Response to Sustained
Orthodontic Forces
The response of teeth to orthodontic forces is a function
of .force magnitude, force distribution, and .force duration .
Sustained pressure causing displacement of a too th within
the periodontal ligament space creates areas of periodontal
ligament compression and areas of periodontal ligament
tension.h. 15 Heavy pressure (greater than capillary pressure)
leads to periodontal ligament necrosis. Bone remodeling
can occur only from undamaged adjacent tissue (undermin-
ing resorption). This creates a delay (1 to 2 weeks) before
tooth movement can occur. On the contrary, a light sus-
tained force induces vascular and chemical changes result-
ing in cellular differentiation and inuncdiate and progres-
sive bone remodeling of the bony socket (frontal
resorption) (Fig. 200-4).
Tipping. This is the simplest fo rm of orthodontic move -
ment When a single force is applied against the crown of
a tooth, the tooth rotates around its "center of resistance"
(Fig. 200-5). This rotation produces an area of compres -
Heavy
Force
Undermining .
resorption : · · · ·
Compression Tension
area or hyalinization +
potential POL necrosis
F;gure 200- 4. Tissue response to sustained Orfhodontic forces. POL, periodonlal ligament
sion at the ape>t on the side of application of the force and
at the alveolar crest on the opposite side. Pressure in these
two areas is high in relation to the force applied to the
crown. The amount of force varies with the size of the
tooth. Experiments in dogs and cats and clinical experience
with humans suggest that tipping forces should be approxi-
mately 50 to 100 grams.1· t3. 15. 16
Bodily Movement (Transla tion). This is obtained when
two forces are appl ied simultaneously to the crown of a
tooth. The apex and the crown of the tooth move in the
same direction. The compression area extends from the
alveo lar crest to the apex on the side opposite the applica-
tion of the foTce (see Fig. 200- 5). The pressure area is
larger, and about twice as much force is required for trans-
lation as for tipping. Experiments. in dogs have shown that
mandibular second premolar teeth can be moved with di-
rect bone resorption by a force in the range of !50 grams.4
Rotation. Rotation of a tooth along its long axis, most
of the time, also induces a tipping movement, and although
in theory the entire periodontal ligament is loaded during
rotation, the same forces used for tipping are used for
rotation.
Extrusion. Extrusion would in theory induce only ten-
sion but is, like rotation, accompanied by tipping, and
subsequently the same magnirude of force is recommended.
Intrusion. This will indure a concentrated tension area
at the aJX:x of the tooth, and although it may be accompa-
nied by tipping, a lig)1t force is required.
Influence of Force Dura tion
Biological considerations and clinical experience suggest
a threshold for force duration at about 4 to 6
Duration of force is related to how force magnitude de-
creases as the toolh moves. On this basis, forces can be
classified in three categories. Continuous force decreases so
slightly as the tooth moves that it can be considered con-
Light
Force
Frontal New bone
resorption apposition
Alveolar Periodontal
bone ligament

A B
Figure ZOO-S. area.'
during tipping or bodily movement.
(From HenneL P: Orthodontics in
small carnivores. In Crossley DA,
Penman S [eds l: Manual of Small
Anim1.1l Dentisrry. 2nd ed. British
SmaJI Animal Veterinary Associa-
tion, Cheltenham, UK, 1995. with
permission.)
Center of resistance
stant. It produces the most effective tooth movement when
light forces are used. This can be achieved with thin and
long wires (incorporation of loops or springs enables in-
creased length). Interrupted force is characterized by a de-
crease of the force magnitude to zero between activations.
Such force can be obt<Uned with u large-diameter (thick)
wire. Intermittent fora is characteri1.ed by an intermittent
abrupt decline of the force to LCro every time the load is
released (removal of the appliance, for example). A func-
tional appliance like the inclined plane used for base-nar-
row canines may produce such force.
A light continuous force would seem ideal, but it cannot
always be achieved. Heavy continuous forces are the most
damaging for the tissue. Moderate heavy forces can be
used if the force is allowed to decline to zero between
activation (interrupted force). It takes about 2 weeks for
undermining resorption to occur, and the appliance should
not be reactivated more frequentl y than at 3-week intervals
to allow bone remodeling.
Anchorage
Anchorage is usually provided by one or several teeth.
Bridging with orthodontic bands or wiring several teeth
together as a unit provides a reinforced anchoraxe. Tipping
requires less force than lranslation; subsequently applying
bodily movement to the tooth used as anchorage helps if
root surface areas of the teeth are similar (stationary an-
chorage). In an experiment on translation of mandibular
second premolar teeth in dogs, tipping of the anchorage
(mandibular first molar and fourth premolar teeth) was ob-
served when a translation force in the range of 150 grams
was used.'1
A rough approximation of anchorage can be based on
root surface area, although this is influenced by bow much
of the roots are implanted in lhc bone, the type of bone,
and the periodontal health. Estimated tooth root surfaces in
the dog have been proposed, but these have ·not been con-
Orthodontics 269t
Relative loading of
compressed areas of
periodontal ligaments
finned by scientific studies. 21 Root surface area of the max-
illary canine in cats is about go% of root surlace area of
the maxillary third and fourth premolars as an anchorage
unit. This suggests that anchorage to move the maxillary
canine tooth should he at least composed of maxillary third
and fourth premolar teeth in cats.
Tooth Movement
Studies in dogs have shown that tooth displacement by a
light continuous force can be separated into four phasest2. 14 :
Phase 1: Initial movement of the tooth. The rate of tooth
movement is significantly correlated to force level.
Phase 2: Almosl no movement is observed whatever the
force magnitude is. This is most likely related to hyalin-
i:L.ation in the periodontal ligament.
Phase 3: This is the real beginning of tooth movement with
an increasing velocity.
Phase 4: The movement becomes linear, and the tooth
moves with a constant rate. Individual rates of tooth
movement are not entirely predictable.
Deleterious Effects of
Orthodontic Treatment
Crown. Too aggressive preparation of the crown surface
through acid etching may be responsible for enamel decal-
cification. Other side effects, especially in very young
dogs, may be metallic staining of the crown surface possi-
bly due to corrosion. The stain may extend deep and may
require polishing and sometimes excavation and restoration
to be removed.
Pulpal Tissue. A torque force or a bodily movement
force of 3 ounces applied on three mandibular incisors in
dogs has caused disruption of the odontoblastic layer in the
pulpal tissue. 2 Potential severe pulpal consequences must
2692 Dentistry

be considered when high continuous forces are used.
Crown discoloration may be an indication of pulpal hemor-
rhage or necrosis.
Root. Cementum remodeling can induce changes in the
shape of the roots. Use of high forces increases the risk of
root resorption. Even with slight forces, root resorption
cannot be completely avoided. The extent of root resorp-
tion is highly variable, but discontinuous force causes les
root resorption than continuous force. 12
Tooth Mobility and Pain. With the increasing magni-
tude of force, pain and tooth mobility increase. Animals
care less likely to tolerate an orthodontic device if the
treatment is painful. Pain is usually observed within the
first 3 or 4 days.''
Undesired Tooth Movement. Ill-conceived orthodontic
techniques may result in abnormal di!.placement of teeth.
Overcorrection may occur as well as abnormal tipping o f
teeth by the incorrect use of elastics or activated wire.
Because of the potential side effects of orthodontic treat-
ment, the animal is closely and regularly monitored during
treatment. Radiographs are obtained at the end of the treat-
ment to assess any deleterious effect on the pulp or root,
especially when tipping canine teeth.
ORTHODONTIC TREATMENT
STEPS
After the nature of malocclusion (dental or skeletal) has
been detennined, the type of treatment and appliance, the
approximate duration and cost, the success rate of the
planned treatment, and the alternatives must be discussed
with the client. The dental health status of the animal is
taken into account; dogs or cats with periodontal disease,
stomatitis, or fractured teeth must be appropriately treated
before orthodontic treatment is performed. It is also impor-
tant to assess the behavior of the animal and the motiva-
tion of the client.
Brackets are often used in human orthodontics; they may
be used in animals, but they are more likely to be dis-
lodged than more retentive devices such as orthodontic
bands.
Cementation
Ln fitting an orthodontic device, small adjustments may
be necessary. There are various types of orthodontic ce-
ments. Many require acid etching of the tooth surface.
Resin-reinforced glass ionomers do not require acid etching
of the enan1el, provide a strong bond to tooth surface, and
are preferred.
Activation
Functional appliances are loaded by function and do not
require activation. Lnclined planes may be "activated" by
modifying the slope of the incline during treatment. Most
active appliances require activation, which is usually cre-
ated by opening or closing a loop, bending a wire, or
turning a screw. Activation of appliances designed to move
teeth should not be performed more frequently than every
3 to 4 weeks. During treatment, the client is advised to
perform tooth-brushing and cleaning of the orthodontic ap-
pliance with a chlorhexidine solution or gel.
Retention
At the end of the orthodontic treatment, the tooth is still
mobile because tissue remodeling is not completed. Re-
modeling of the periodontal ligament requires about 3 to 4
months. Ln humans, retention lasts 3 to 12 months, depend-

Obtaining Impressions and

Stone Models
Lmpressions are obtained to manufacture a stone model.
Direct build-in techniques do not require a stone model;
however, study models are highly recommended for record
keeping, client education, and treatment planning. The
model can be poured by the practitioner or by an orthodon-
tic laboratory.

Dental Laboratory
The veterinary dentist must plan the design of the appli-
ance and the type of treatment and instruct the dental
laboratory accordingly. Veterinary orthodontic appliances
are mostly fixed appliances. They may be functional (inac-
tive) appliances, such as bite or inclined planes, or active
appliances incorporating wires, loops, springs, or screws. Figure 200-6. Surgical inclined plane cremed by gingivopla\ly in the
Removable appliances may be held in place with clasps. interdental space.

Figure 200- 7 . Functional removable maxillary orthodontic appliance: orthodontic bands cemented (A) and device installed (8). (From Hennet P:
Orthodontics in small carnivores. In Crossley DA, Penman S [eds): Manual of Small Animal Dentistry, 2nd ed. British Small Animal Veterinary
Association, Cheltenham, UK, 1995, with pennission.)
ing on the movement of the tooth. In carnivores, because
of the interdigitation of teeth, natural retention can shorten
the retention period. Retention can be performed by a non-
activated orthodontic appliance left in place or by a spe-
cific retention device.
Removal
Orthodontic bands and brackets are removed with appro-
priate instruments. Orthodontic bands may be split to facili-
tate removal. A scaler or periodontal chisel is useful to
remove cement from the tooth surface. Once the appliance
and the cement have been removed, a thorough periodontal
treatment is performed, including polishing.
Figure 200- 8. Active mandibular W orthodontic wire.
Orthodontics 2693
CORRECTION OF COMMON
MALOCCLUSIONS
"Base-Narrow Canines"
This is a common and sometimes painful malocclusion.
The mandibular canines impinge on the palatal mucosa,
which can even lead to oronasal fistula formation. When
orthodontic correction is not elected, crown height reduc-
tion may be a satisfactory alternative.
Malocclusions in this group can be separated into three
categories on the basis of the sagittal relationship of the
mandibular canine teeth, which may occlude mesial, pala-
tal, or distal to the maxillary canine teeth.
In young dogs (younger than 7 months), canine teeth
may not be fully erupted, and an appliance bonded to the
maxillary canines would erupt with the teeth or prevent full
eruption.'' Treatment options include the following:
Figure 200- 9. Inclined plane bite plate. An intemlittent force is ere·
ated by masticatory muscles closing the mouth of the dog.
2694 Denustry
Figure 200- 10. Bonded vcslibular wire and onhodomic modulus 10 induce veslibulovcrsion of an incisor. A, During 1rca1mcn1. 8, Afler 1rcauncn1.
I. A functional treatment based on the regular chewing
of an appropriate round rubber ball to induce vestibulover-
sion of the reeth. 2o
2. Jaw remodeling by surgical creation of a groove into
the maxilla between the maxillary canine and the third
incisor to create a natural inclined plane. This can be done
by gingivectomy if the tip of the canine is buccal or by
raising a Hap and removing some bone in the interdental
space if the tooth occludes farther palatally (Fig. 200-6).
3. A removable maxillary orthodontic appliance, by
means of orthodontic bands bonded to the canine teeth to
hold an incl ined plane, which is maintained only by ortho-
dontic clasps (Fig. 200- 7).
4. A W spring, bihelix, or quad helix on the mandibular
canine teeth. In this case, the device needs to be activated,
taking into consideration both the vestibuloversion and the
eruption of the teeth (Fig. 200-8).
Figure 200- 11 . Active maJ(IIIary device: palatal spring.
In dogs older tha n 7 months, the same techniques can be
used. In most cases, correction is best with an inclined
plane. This functional appliance provides an intermittent
force created by masticatory muscles closing the mouth of
the dog (Fig. 200-9). Adjusting the slope of the inclined
plane allows correction of nonsymmetrical defects, which
is more difficult to achieve with a mandibular device. The
slope can also be prepared to move the tooth rostrally and
buccally. Use of an acrylic or composite inclined plane
instead of a metallic one permits easy moditicarions of the
slope during treatment. In young dogs, the appliance
should not restrict sagittal and transverse growth; therefore,
a telescopic appliance must be used.
Rostral (Anterior) Crossbite
One to six incisors may be affected and may be affect-
ing only one side. Malocclusion involving all incisors is
Figure 200- 12. Strain gauge used to adju'>t 1ension of an onhodontic
chain. (From Hennet P: Orthodontics in small carnivores. In Cro\\ley DA,
Penman S Manual of Small Animal Drmistry. 2nd cd. Bnll\h Small
Animal Veterinary Cheltenham, UK. 1995, with pcrmi\\ion.)

Figure 200- 13. Acllve device with an orthodontic chain and rein·
forced anchorage.
most likely of skeletal ongm. Palatoversion of only one
incisor may be corrected early (before 7 months of age)
with a vestibular wire bonded to the third incisors and an
elastic force between the affected incisor and the wire. This
can be done directly intraorally (Fig. 200- I0). More com-
plex malocclusion!> require the making of an orthodontic
device by a dental laboratory, such a!> a palatal spring
bonded to the maxillary canine, which can be activated
with pliers to induce vestibuloversion (Fig. 200-11). ln
some cases, a device may have to be placed on mandibular
incisors to induce linguoversion.
Rostrally Displaced Maxillary
Canines
Rostral displacement (rostroversion or mesioversion) of
maxillary canine teeth may be associated with persistent
deciduous teeth. The goal of the treatment is to induce a
distOversion of the maxillary canine. Brackets and elastic
bands or chains may be used. A strain gauge is used to
adjust tension (Fig. 200- 12). Proper anchorage is manda·
tory. Reinforced anchorage should, at least, use the maxil·
lary fourth premolar and the first molar or the second and
third premolars. A palatal wire can also bond the premolar
teeth to the opposite maxillary canine if only one canine
tooth is affected. Simple placement of an elastic between
the canine and the fourth premolar results in the displace-
ment of the latter tooth as well. Alternatively, tooth extrac-
tion may be performed.
OrthOdOntiCS 2695
Rostrally Displaced Mandibular
Canines
Rostrally displaced mandibular canines occur in dogs
and cats but are often associated with a skeletal malocclu-
sion (maxillary brachygnathism). If not, the same type of
techniques as for maxillary canines can be used (Fig. 200-
13). Moving mandibular canine teeth is more difficult than
moving maxillary ones because of denser bone.
References
I. Anonymous: Glossary of Dentofociol Ortllopt'dic Tt'rms: Ortllodomtc
Glossary. American of Orthodonti.,..,, St. Louis. 1981.
2. Anstendig l iS. Kronman JH: A histologic study of pulpal reacuon to
orthodontic tooth movement in dogs. Anglr Ortltod 42:50, 1972.
3. Beard G: Anterior crossbite: lnterceptive orthodontics for prevention.
Maryland bridges for correction. J Vet Delli 6: 14, 1989.
4. Fortin JM: Translation of premolars in the dog by controlling the
moment-to-force ratio on the crown. Am J Ortltod 59:541, 1971.
5. Fricker JP: Orthodontics and Dt'ntofaciol Ortltopot'dics: A Comprr·
hensi,·e TwOOiJS. Tidbinbilla Ltd. Canberra, 1998, p 26.
6. Furstrnan L, et al: Differential respono;e mcident to tooth movement.
Am J Orthod 59:600, 1971.
7. Gianelly AA: Force-induced changes in the vascularity of the peri·
odontaJ ligament. Am J Orthod 55:5, 1969.
8. Goz GR, et al; The effects of horizontal tooth loading on the circula·
tion and width of the periodontal ligament- an experimental study on
Beagle dogs. Eur J Orthod 2/:671. 1999.
9. Harvey CE. Emily P: Small Animal Denustry Mosby- Year Bool.. St.
Louis, 1993.
10. Hennet P, Harvey CE: Diagnostic approach to malocclusions in dogs.
J Vrt Delli 9:23, 1992.
II. Hennet P: Orthodontic vtttrinaire. partie: le tmitemcnt.
Prot Med Chir Anim Comp 30:311, 1994.
12. Kuijpers-Jagtman AM, et al: Back to basics: Tooth movement in
orthodontics. In Carets C. Willems G (cd'>): Tht Futurt' of Ortlux/an·
tics. Lcuven University Press, Lcuven, 1998. p 117.
13. Loescher AR. et al: Characteristics of periodontal
supplying cat canine teeth which have sustained orthodontic forces.
Arch Oral Bioi 38:663, 1993.
14. Pilon J. et at: Magnitude of orthodontic forces and rate of bod•ly
tooth movement. An experimental Am J Ortlwd Dentofac Or·
thOIJ JJO: 16, 1996.
15. Proffit WR: Comemporary Orthodontics, 2nd ed. Mosby- Year BooJ..,
St. Louis. 1993.
16. Reitan K: Effect'> of force magnitude and direction of tooth move-
ment on different alveolar bone types. Anglt' Orthod 34:244. 1964.
17. Shipp AD, Fahrenkrug P: Practitioners' Gwdi' to Veterinary Dt'n-
tistry. Dr Shipp's Laboratories, Beverly llills, 1992.
18. Stockard CR: The Gt'lletic and Endocrinic Basis for Differmct's 111
Form and Beh01•ior. The American Anatomical Memoirs Nr. 19. The
Wistar Insti tute of Anatomy and Biology. Philadelphia, 1941.
19. Vander Linden F, Boersma H: Diagnosis and Treatment Planning in
Dentofacial Orthopedics. Quintessence Publishing, London. 1987. p
39.
20. Verbaert L: A removable orthodontic device for tbe treatment of
lingually displaced mandibular canine teeth in young dogs. J \ tt
Dent /6:69, 1999.
21. Wiggs RB. Lobprio,e HB: Veterinary Dentistry: Principlt's 011d Prac·
tice. Lippincott-Raven, Philadelphia, 1997, p 435.
C H A P T E R
201
Exodontics
Frank J. M. Verstraete
Exodontics (or exodontia) deals with tl1e exlra<.:t.ion of
teeth and entails a number of important tec hniques and
skills that a practitioner must master. In spite of the many
advances in veterinary dentistry, many indications for the
exlraction of teeth remain, and extractions are commonly
perfonncd in clinical practice. The frequency with which
extractions arc performed contrasts with the amount of
training that most veterinarians have received in this field.
The size and shape of some teeth in carnivores, such as the
canines and carnassial teeth, and the nature of the disease
processes that 1nay affecL the teeth, such as ankylosis and
odontoclastic res()rption, make exlraction challenging. With
appropriate planning based on pre-extraction radiographs,
proper instruments , and application of correct techniques,
teeth can and sho uld be delivered atraumatically, intact,
and without undue effort.
GENERAL CONSIDERATIONS
Indications
Severe periodontitis is the most common indication for
extraction of teeth. The mobility index and the furcation
index (for multirootod teeth) are the most important factors
in the decision-making process.36 Once periodontitis has
caused so much bone loss that the tooth is very mobile,
extraction is the treatment of choice. A multirooted tooth
with a through-and-through furcation lesion can be main-
tained with exceptional home care, but extraction is indi-
cated if this cannot be assured.
Deep crown-root fractures e xtending under the level of
the alveolar margin lead to rapidly progressive periodontitis
with vertical bone loss and are generally an indication for
extraction.2 Root fractures of the coronal third of the root
are unstable. necessitating extraction.2
Teeth in a maxillary or mandibular tracturc line that are
not contributing to fragment stability or are periodontally
diseased should be removed (see Chapter 153). If a tooth is
secure in the: alveolar bone, it is retained because it may
contribute to fracture fixation. Manipulation of the fracture
fragment associated with extraction may be harmful.
Deciduous teeth nonnally exfoliate when their pennanent
successors erupt. lf this does not happen, persistent decidu-
ous teeth are extracted when they are diagnosed because
they may influence the time and direction of eruption of
the permanent teeth. Permanent incisors erupt immediately
caudal to the persistent deciduous incisors. Persistent decid-
uous canines cause linguoversion of the erupting mandibu-
2696
Jar canines and facial deviation of the maxillary canines.
Furthennore, persistent deciduous teeth alter the gingival
contour, which results in accumulation of plaque between
the deciduous and permanent teeth. The early extraction of
deciduous teeth to prevent malocclusion of the permanent
dentition is refe rred to as interccptive orthodontics.3s. so
Fracture of a deciduous tooth with pulp exposure may
lead to periapical pathosis and affect the underlying devel-
oping permanem tooth, necessitating exlraction of the de-
ciduous tooth when the diagnosis is made. 50
Supernumerary teeth interfering with occlusion or peri-
odontal heallh arc also an indication fur extraction. The
normal number of teeth may be present, but crowding (the
abnonnally close and irregular positioning of teeth) may
occasionally lead to early periodontitis. These animals may
benefit from extraction of selected teeth.511
Embedded and impacted teeth are often associated with
dentigerous cyst fonnation and should he extracted, espe-
cially in young animals.l2. 13
Feline odontoclastic resorption lesions are a common
indication for extraction (see Chapte r I 95). Although resto-
ration may be attempted for superficial lcsi()ns (see Chapter
199), extraction is generally the treatmenL of choice. Ex-
traction is complicated by root resorption, which makes the
teeth susceptible to iatrogenic root fractures.
The extraction of all premolars and molars, or even all
teeth, is an accepted therapy for chronic stomatitis in cats
that have failed to respond to medical treatment. 19
ln animals with oral tumors, teeth affected by periodon-
titis or endodontal disease, or surrounded by neoplastic
tissue, are extracted before radiation lreaunent to minimize
osteoradionecrosis.3
A number of conditions can be treated conservatively by
endodontic or restorative dentistry but may be indications
for exlraction if conservative treatment is not elected (e.g.,
crown fractures with pulp exposure, pulpal necrosis, and
caries). Extraction is also the treatment of choice if con-
servative treatment is no longer feasible (e.g.• advanced
caries with major loss of dental substance, periapical pa-
thosis with inflammatory root resorption, or severe peri-
odontal-endodontal lesions).
Individual maloccluding teeth that are not amenable to
orthodontic correction may require extraction if they cause
tissue trauma.!' Linguoversion of the mandibular canines
can be treated by orthodontic means or by crown amputa-
tion and par l.ial coronal pulpectom y; extraL:tion is less de-
sirable.
Uncontrollable aggression is rarely a valid indication for
dental exlraction because dental extractions may have little

Figure 201 - 1. Dorsal position of a dog for extraction procedures; note
the excellent exposure of the palatal root of the maxillary fourth premolar
(arrow).
effect on the behavior of the animal. In such cases, behav-
ior therapy is the treatment of choice.
Informed consent of the client is required before a pet's
tooth is extracted. It is also prudent to ask the client
whether the extracted teeth may be discarded.
Preparation of the Operator
As with periodontal treatment, the operator wears a mask
and protective eyewear to prevent contact with the bacte-
ria-laden fluid particles that are generated during the proce-
dure. Splashproof face shields are adequate for simple ex-
tractions, but protective goggles are indicated if a dental
drill is used to remove bone or to section teeth.
Positioning of the Patient
Lateral recumbency is preferred by most veterinarians. It
is important to place a towel or similar sandbag under the
neck of the patient and tilt the head downward to ensure
adequate drainage of saliva and irrigating fluid. Lateral
recumbency offers good exposure of the buccal surfaces of
the uppermost teeth but only fair exposure of lingual sur-
faces of the opposite arcade. Consequently, the patient
must be turned over halfway through the procedure. Dorsal
recumbency offers the advantage of superior exposure of
all aspects of the teeth, especially those of the maxillary
dentition. The patient can remain in the same position
throughout the procedure. The main hazard of dorsal re-
cumbency is fluid aspiration. A towel, sandbag, or fluid
bag under the neck of the animal is essential to ensure that
the palate is in a horizontal plane; lowering the head of the
table slightly is also recommended. The use of a cuffed
Exodontics 2697
endotracheal tube and pharyngeal pack is necessary to pre-
vent aspiration. Continuous suction is helpful.
Lateral and dorsal recumbent positions are adequate for
most extractions. Dorsal recumbency is indicated for surgi-
cal extraction of the caudal maxillary teeth because it al-
lows adequate exposure for sectioning of the palatal root
(Fig. 201- 1).
Pre-extraction Radiographs
Pre-extraction radiographs of teeth to be removed are
always indicated to confirm the diagnosis, to allow visual-
ization of the root morphology, to ascertain the presence of
root resorption or root ankylosis, and to assess the quality
of the supporting jaw bone. With a persistent deciduous
tooth, it is important to know whether and to what extent
physiological root resorption has taken place. Anatomical
variations and developmental conditions are common in the
dog and cat, and their presence may influence the extrac-
tion technique 53- 55 ; examples include supernumerary roots,
fused roots, and root dilaceration (Fig. 201-2). Postextrac-
tion radiographs are recommended to confirm that no root
tips have been left behind and to document possible alveo-
lar bone injury due to the extraction procedure.
Aseptic Technique
The general principles of aseptic technique also apply to
dental extractions, although it is impossible to work in a
sterile fashion within the oral cavity. It is good practice to
remove dental calculus and subgingival debris and to flush
the mouth subsequently with a suitable antiseptic solution
before oral surgery. 51 Extraction instruments are sterilized
before use. Full aseptic technique (drapes, sterile field) is
used for surgical extractions; surgically clean technique is
sufficient for simple extractions. 23
Figure 201 - 2 . Malformed mandibular first molar with periapical pa-
thosis, illustmting the need for pre-extraction radiography.
2698 Dentistry
Preventive Use of Antibiotics
Most oral .surgery falls into the categories of clean-con-
taminated and contaminated surgical wounds. 32 Like peri-
odontal treatment, tooth extraction causes considerable bac-
tcremia.4 This bacteremia typically clears within 10 to 20
minutes.39 Antibiotic prophylaxis is necessary only in geri-
atric or debilitated animals, in patients with preexisting
heart disease or systemic disease, in
patients, when extensive surgical extractions are plaMed,
and with gross infection and chronic stomatitis.
Because of the bacteremia, tooth extractions are not per-
formed with other surgical procedures.!'· 58 The bacteremia
may be an endogenous source of wound infection. Inquir-
ing clients are advised that combining an elective surgical
procedure with periodontal treatment and extractions is not
in the best interest of their pet. However, perfonning a
concurrent minor surgical procedure in a geriatric or debili-
tated patient may be justifiable because it saves an anes-
thetic episode. This decision is left to the clinical judgment
of the veterinarian.
T he choice of antibiotic and administration protocol re-
main controversial, both in human and in veterinary ora l
surgery. 30, 32 Recommended antibiotic protocols for human
patients focus on prevention of either bacteremia (typically
conceived for endocarditis prevention) or wound infec-
tion.11· 32 However, the principles of correct use of antibiot-
ics apply to both, and it is possible to achieve both goals
with one protocol (Fig. 201- 3). First, the causative organ-
ism must be known. A wide variety of microorganisms are
present in the normal oral flora of the mouth and saliva
and in oral cavities with periodontal disease. In general,
antibiotic prophylaxis requires antimicrobial activity against
gram-negative, gram-positive, and anaerobic organisms.s
Linked to this is the requirement that the antibiotic
tibility of the causative organism be known. The timing of
r - -·-
;
! A11tibiocic
L Sy$1emic Cardiac problems i I
r -···· -·--+--t
Antlbiolic prophylaxis mdJcoted ...__.__
1441
_ __
fo r ueatmonl of fa
1 L___ _ _ __ _
[ .- - -- - .....---- -
Amp icillin 20 malka l V allho
time of catheter placem ent for
ancsthos1a
j Ampicillin 20
I after 6 bou.l"$ if calheter still in
1 plac.c
Figure 201-3. Preventive use of antibiotics in oral in dogs anti cats.
administration of antibiotics is critical. Antibiotics must be
administered within 2 hours before the procedure and not
be continued for more than 4 hours after the procedure.s. 32
Last, antibiotics must be given at a dose high enough to
reach a tissue level four times higher than the minimal
inhibitory concentration of the causative organisms.
The protocol recommended in Figure 201-3 is based on
these principles and derived from current recommendations
in hwnans.48 Whereas the standard protocol in humans calls
for oral medications, this is not indicated in animals be-
cause general anesthesia is required. Ampicillin, amoxicil-
lin-clavulanic acid, certain cephalosporins, and clindamy-
cin meet these requirements in dogs, cats, and humuns.s. 17.
18 24 28
• • Clinical studies in humans have shown similar
efficacy.24• 37 Ampicillin and amoxicillin- clavulanic acid
have good penetration in soft tissues and sulcular ftuid. 45
Clindamycin has good penetration in bone and sulcular
fluid43 • 57; more specifically, tissue samples obtained during
maxillofacial procedures showed high levels of clindamy-
cin.28 Clindamycin is a good alternative to ampicillin but is
unfortunately not available for intravenous use in animals.
Metronidazole can be given intravenously in addition to
ampicillin, in severe cases, to ensure a wider anaerobic
spectrum.
Antiseptics
It is good practice ·to rinse the mouth with a suitable
antiseptic solution before, and during, oral surgery:n Chlor-
hexidinc gluconate in an aqueous, non-alcohol-containing
solution is the antiseptic of choice in animalsY Povidone-
iodine is most commonly used in humans and decreases
the bacteremia. 42 The correct concentration of chlorhexidine
should be used; although 0.2% is generally recommended
as being safe, a more dilute sol ution (0.05%) may be ind.i-
-···-- - ---,
indicated?
- - , ..... __1 _----,
, :]
l.::.o indialion for .
Llliotic prophylaxis
l r---·· ·t =
-
Antibiotic propbylaxb indicated
No antibiotic prophylaxis
for prevention of wound infection
I
•• __!
IV repeated

Figure 201-4. A. Apcxo 301 elevator. 8. Luxator. (Cour-
A
of ll u· Pricdy, C hicago, lll.)
cated if the oral mucosa to the solution through-
out the procedure. Great care is taken to avoid the eyes.27
Surgical Principles
A tooth is held in place by Sharpcy's fibers within the
periodontal ligament, connecting the alveolar bone to the
root cementum.1• 44 The basis of the extraction procedure is
to stretch and se ver these fi bers to loosen the tooth with
minimal trauma to the surrounding tissues. If the periodon-
tal ligament fibers are complete ly severed, virtually no ex-
traction force is necessary to deliver a single-rooted tooth. 29
Good exposure and visibility make tooth extraction
much easier to perform. Proper positioning, good lighting,
irrigation, and suction are factors affecting visibility. It is
equally important to have tJ1e correct and well-maintained
instruments.
Instruments
The following paragraphs introduce the instruments used
in extraction procedures in broad terms. The examples
mentioned represent my preference; many other alternatives
are available.
Elevators and Luxators
Dental e levato rs and luxators arc the most important
instruments for an extraction procedure and are used to
loosen the root from the periodontal ligament. There are
subtle but important d ifferences in instrument design and
usage between e levators and luxators (Fig. 20 1- 4). Luxa-
tors (e.g., Ericsson luxators·) have sharp and relatively flat
blades used in a linear fashion to cut the periodontal liga-
ment and to app ly vertical or wedge leverage. Elevators
(e.g., Apcxo or Heidbrink elevators•) are used more to
' llu-Pricdy. Chicago, Ill.
A
Figure 201 - 5 . Heidbrink number I (A) and Davis number
II (8 ) root t1p elevators. of Hu-Friedy, Chicago, lll.)
B
Exodont1cs 2699
loosen and lift roots by horizontal leverage. Their tips vary
in shape, but they usually have a nat face and a rounded
back. It is imperative that the tips of dental elevators and
especially th ose of luxators be kept sharp. A sharpening
stone can be used for this purpose.
Root tip elevators (root tip picks) are sharp, delicate
instruments designed for the removal of human root tips
(Fig. 201 - 5). They are used for the same purpose in dogs
and cats but can also· be used as conventional elevators for
very small teeth.
Extraction Forceps
In human dentistry, special extraction forceps have been
d esigned for each kind o f tooth. Many of these forceps are
unsuitable for use in the dog and cat. Sharply curved for-
ceps, such as the so-called lower molar forceps, and for-
ceps with sharp triangular tips are particularly likely to
cause root fractures. Extraction forceps designed for veteri-
n ary use are available, but a selection of suitable instru-
ments from human dentistry can be used. For example, so-
called upper anterior forceps (such as the pedodontic Cryer
number ISOS and the even smaller number 150K ) are
suitable for use in the dog and cat (Fig. 201 - 6A).9 • 5 1
These forceps have a slightly conical grip and fit most
teeth, in spite of the great variation that exists in the size
and shape of teem in dogs and cats. Root forceps, such as
the number X49 forceps• (Fig. 20 I -68 ), diffe r from con-
ventional extraction forceps in that the beaks of root for-
ceps close; an opening remains between the beaks of ex-
traction forceps.
Additional Hand Instruments
Gingival and mucogingival fl aps arc commonly used in
l>Urgical extraction techniques. A small periosteal e levator,
such as a number P24G• (Fig. 201 - 7A}, is used to raise a
flap. Once the flap is raised, it can be protected by a tissue
' llu-Fri cdy, C hicago. Ill.
2700 Dentistry
A B
Figure 201 - 6 . A. Cryer number 150S upper amerior forceps. 8, Num-
ber X49 root tip forceps. (Counesy of Ilu-Fricdy. Chicago, Til.)
retractor, such as a Seldin retractor· (Fig. 20 I -78). A
smaJI curette, such as a Miller number 9/10 curette• (Fig.
201-7C), may be used to clear the vacated alveolus of any
debris on completion of the extraction procedure.
Rotary Instruments
Rotary instruments are used for sectioning teeth and re-
moving and smoothing alveolar bone. A high-speed hand-
piece with a taper diamond burr or a carbide crosscut
fissure burr is indicated for sectioning multirooted teeth
into single-rooted units in a safe and predictable fashion. A
slow-speed handpiece with a diamond disc has been used
in the past but cannot be recommended because of the
hazard of inadvertently traumatizing oral soft tissues.
An autoclavable, high-torque, straight surgical handpiece,
with built-in sterile fluid irrigation capability and a round
carbide burr is the instrument of choice for bone re-
movaJ.33.47 A high-speed handpiece with a round diamond
or carbide burr is generally used in veterinary dentistry. 20
This practice is frown ed on in human oral surgery because
the air exhausted from this type of handpiece may be forced
into deeper tissue planes and produce tissue emphyscma.U
'Hu-Friedy. Ch1cago, Ill.
. ····'\:··;:· . -- .. - . --· - . . ·: .··.
A
B din rcl1'3clor. C. Miller curene number 10. (Courte\y of Hu-
c
Simple versus Surgical
Extraction
In a simple (closed) extraction, the periodontal ligament
is severed with dental elevators or luxators. The extraction
can be completed without the need for sectioning the tooth,
creating a gingival or mucogingival Hap, or removing alve-
olar bone, all of which form part of a surgical extraction. It
is important to anticipate or to recognize the necessity for a
surgical extraction early in the extraction procedure. This
decision is based on pre-extraction radiographic findings.
For example, it is unwise to attempt a simple extraction of
a maxillary fourth premolar with a complicated crown-root
fracture that is otherwise in good periodontal health.
SIMPLE EXTRACTION
The epithelial attachment and dentogingival fibers are
severed and access is gained to the coronal part of the
periodontal ligament by introducing a small (e.g., number
15) scalpel blade down the gingival sulcus and along the
entire circumference of the tooth (Fig. 201-SA). Elevators
or luxators arc used to loosen the root from the periodontal
ligament. The technique varies accordirng to the chosen
instrument. The tooth may be delivered with one of these
instruments, or forceps may be used to complete the ex-
traction.
The luxator is gently inserted into the periodontal space
on the mesial side of the tooth (Fig. 201-88). The luxator
is advanced with firm presl.ure and small axial rotations (5°
to 10°), cutting the periodontal fibers to within two thirds
of the length of the root. The luxator is used to loosen the
distal root. The tooth is now dislodged, but if necessary,
the process may be repeated on the lingual side or until the
entire root c ircumference is loosened from its periodontal
attachment. Because these instruments are very sharp, care
is taken to avoid instrument slippage and tearing of the
gingiva, as one is inclined to use considerable force while
introducing them to break down the periodontal ligament.
Severing the periodontal attachment completely minimizes
the risk of a root fracture and often allows the tooth to be
delivered from the alveolus without forceps. This technique
does not usc the adjacent alveolar bone or tooth as a
fulcrum to lever out the tooth.
Elevators arc also inserted gently into the periodontal
space to sever the periodontal fibers. Once enough pur-
chase is obtained , the elevator is used to lift and pry the
tooth out of the alveolus. The tip of the elevator introduced
between the root and the alveolar bone is rotated through a
small angle and held for a few seconds, aJiowing the peri-
................,
Figure 201 - 7. A. Number P24G eleva10r. B. Sel-
Fricdy. Chicago. Ill.)
 ExodontiCs 2701

Figure 201 - 8 . S1mple extracuon procedure of a maxillary fir.t pre-

molar. A, Sulcular incision. 8, The luxator is posuioned in the pcnodon-
tal ligament space at the appropriate angle. C. Delivery of the tooth with
forceps.

odontal fibers to stretch and tear on their own. Gradually,
the tooth is delivered by progressive tearing of periodontal
fibers and first-class or wheel-and-axle leverage. 20 Elevators
can also be used for horizontal leverage, with the adjacent
tooth as a fulcrum; this technique is also applied when an
elevator is introduced between the two units of a two-
rooted tooth after sectioning. In small dogs and cats, a
slender root tip elevator can be used as a dental elevator.
If remnants of the periodontal ligament make it difficult
to lift the tooth out, extraction forceps may be used for
final loo ening. The forceps are placed as apically as possi-
ble on the tooth (Fig. 201-8C), parallel to the long axis of
the tooth. 3 The beaks can be positioned mesial-distal or
buccal-palatal. Once the extraction forceps are securely po-
sitioned on the upper part of the root, the tooth is rotated
through a limited angle while little traction applied. 3 The
tooth is first rotated clockwise and held for a few seconds
in the rotated position, causing the remaining periodontal
fibers to stretch and tear. The procedure is repeated in a
counterclockwise direction.
An alternative method, more applicable to humans than
to dogs and cats, can be used to displace the root from its
socket by forcing the jaws of the extraction forceps into
the periodontal space and thus expanding the buccal and
lingual cortical alveolar bone plates.9 • l t . 46 If loosening of
the root with dental elevators or luxators was adequate, it
should be possible to lift out the tooth without undue
effort. If resistance is encountered, it indicates that a con-
siderable portion of the periodontal ligament is still intact.
ln this case, one should not proceed with the forceps ex-
traction, but loosen the root further with dental elevators or
Juxators.
After extraction, the root is inspected to ensure that
complete removal of the tooth occurred. The empty alveo-
lus is flushed and cleared of any debris. A small curette
may be useful, but overzealous curettage is avoided. A
2702 Dentistry

Figure 201 - 9. Ex1raction of a maxallary canine tooth (with the dog in dorsal recumbency). A, Mucogingival pedicle flap. 8 , Bone removal wath a
round diamond burr on a high-\peed h;mdpiccc. C. Elevmion of 1he loolh. D , The vaca1ed alveolus after £, Surgical closure.

simple extraction wound is generally left unsutured, but
one or two sutures may be used for approximating the
gingival wound edges and securing the blood clot in the
vacated alveolus. Alternatively, the expanded alveolar bone
plates and overlying soft tissues can be approximated by
digital compression.
As a rule, this simple extraction technique applies to all
single-rooted teeth; however, canine teeth with a healthy
periodontal ligament are the exception to this rule. When
extracting incisors, one should not try to rotate mandibular
incisors because they are mesiodistally flattened; care must
be taken not to damage the interdental alveolar bone plate.
The maxillary third incisor has a relatively long, curved
root with a triangular cross-section and lies close to the

nasal cavity; these features make a careful but complete
loosening of this tooth by dental elevators or luxators nec-
essary. Bet:ause of its shape, rotational movements of the
maxillary third incisor are almost impossible.
SURGICAL EXTRACTIONS
Flap Design
Various types of flaps are available for surgical extrac-
tions. Flaps used in surgical extractions are full-thickness,
mucoperiosteal flaps and can be classified as gingival or
mucogingival, depending on whether the flap is confined to
the attached gingiva or crosses the mucogingival line.
An envelope flap is created by making an intrasulcular
incision around the tooth and extending it interproximally
as needed; this may involve adjacent teeth. The attached
gingiva is elevated farther in an apical direction, and the
elevation may be extended to include some of the alveolar
mucosa if needed. 6 With a pedicle (or four-cornered) flap,
two divergent releasing incisions are made in addition to
the intrasulcular incision as described for the envelope
A triangle (or three-cornered) flap involves one vertical
releasing incision in addition to the intrasulcular incision. 14
This is usually done on the mesial aspect to preserve the
blood supply coming from the caudal aspect. Pedicle and
triangle flaps are typically mucogingival flaps. Releasing
incisions can be made intcrproximally6 or at a dental line
angle of an adjacent tooth.34 • 47
Surgical Extraction of Canine
Teeth
A canine tooth is generally difficult to extract because of
its extremely long and curved root. In instances of severe
periodontitis, there is usually enough alveolar bone resorp-
tion on the buccal side to allow enough act:css for the
dental elevators to loosen the entire root surface. In a
periodontally healthy tooth, this is not the case, and some
of the bone must be removed. This procedure is called an
alveolotomy, or a pa1tial alveolectomy, and a full-thick-
ness, buccal mucogingival flap is created to gain access to
the bone (Fig. 201-9) ..
Surgical Extraction of a Maxillary
Canine Tooth
The epithelial attachment is severed by introducing a
small scalpel blade down the gingival sulcus and along the
entire circumference of the tooth. Alternatively and prefera-
bly, the sulcus epithelium can be excised. This incision is
extended interproximally for 2 to 3 mm on the mesial and
distal aspects. On the buccal side of the tooth, two diver-
gent incisions arc made in the gingiva extending into the
oral mucosa (Fig. 20l-9A). A mucoperiosteal pedicle flap
is elevated with a periosteal elevator and reflected, expos-
ing the buccal alveolar bone. Alternatively, a single releas-
ing incision can be made either mesial or distal to the
canine tooth and a triangular flap created. An osteoplasty
Exodontics 2703
burr is mounted on the high-speed handpiece or on the
straight surgical handpiece. With constant irrigation, the
proximal part of the buccal alveolar bone is drilled away
(Fig. 201-98). Alternatively, a groove may be cut in the
bone overlying the contour of the root. 20 lf a dental drill
unit is not available, the alveolar bone plate is nibbled
away with bone rongeurs. While the bone is removed, the
mucogingival flap is retracted with stay sutures or a retrac-
tor. It is important that the buccal flap be wider than the
bone defect so that the suture line will be supported by
intact bone.
The dental elevator or lu.x.ator can now be inserted more
deeply into the periodontal space (Fig. 20l-9C). One may
start luxating on the mesial and distal aspects of the tooth
and gradually move in an apical direction. Once some
progress has been made, the luxator can be introduced on
the mesiopalatal aspect. If the whole root cannot yet be
loosened, more alveolar bone is removed. Slightly curved
dental elevators can also be used. Final delivery is
achieved with forceps. Because of the oval cross-section of
the root, rotational movement<> are possible only through a
limited angle.
After removal of a maxillary canine, it is important to
check whether a communication with the nasal cavity has
been created, evidenced by ipsilateral nose-bleeding. This
can be caused by the avulsion of a pa11 of the alveolar wall
during extraction or by periapical bone destruction due to
chronic inflammation. This can lead to a persistent oronasal
fistula.
After an alveolotomy, sharp bone edges preventing
smooth soft tissue closure can be removed with an osteo-
plasty burr, bone rongeurs, or small file; this procedure is
called alveoloplasty (Fig. 201-9D). The empty alveolus is
cleared of debris, and the mucogingival edges are easily
approximated and sutured in a simple interrupted pattern
(Fig. 201-9£). Fine, monofilament, synthetic, absorbable
suture material· is recommended. If communication with
the nasal cavity occurred, great care is taken in closing the
extraction wound completely.
Surgical Extraction of a Mandibular
Canine Tooth
The mandibular canine tooth can be surgically extracted
in a similar fashion; however, lhe flap design is different
because of the presence of the lip frenulum. After the
sulcular incision as described before, the incision is ex-
tended interproximally tor 2 to 3 mm on the mesial aspect.
From this point, the mesial releasing incision is made in a
caudoventral direction, mesial to the lip frenulum. On the
distal aspect, an interproximal incision is made up the
second premolar. The mucoperiosteal triangle flap created
is raised and reflected in a caudoventral direction and in-
cludes the lip frenulum and associated mental blood vessels
and nerve. The buccal alveolar bone is partly removed, and
the tooth is delivered as described before. Great care is
taken in elevating or luxating the to01h completely. The
premature application of the forceps may cause a fracture
between the alveolus and the mandibular symphysis.
·Poliglccaprone (Monocryl), Ethicon, Somerville, N.J.
2704 Dentistry
The mandibular canine tooth may also be extracted by a
lingual approach. 40 A mucoperiosteal pedicle flap is created
on the linguodistal aspect of the tooth. Similar quantities of
bone are removed to expose the tooth. root, compared with
the more commonly used buccal approach.
Surgical Extraction of Two-
Rooted Teeth
If significant alveolar bone resorption has taken place
because of periodontitis, the smaller premolars can be lifted
out intact after thorough loosening of the periodontal at-
tachment. ln most cases, it is better to section the tooth
into two parts, thus creating the equivalent of two single-
rooted teeth. After the gingiva is loosened from the crown
and retracted, the furcation of the root is usually visible.
To achieve a better exposure of the furcation of the root,
the incision can be extended interproximally and a small
gingival envelope flap created (Fig. 201-IOA). On occa-
sion, it may be indicated to remove 2 to 3 mm of the
alveolar margin. If a dental drill is available, the tooth is
easily sectioned with the high-speed handpiece. Sectioning
preferably starts at the furcation; this is the most critical
Figure 201-10. Extraction of a maxillary second premolar (with
the dog in dorsal recumbency). A, A gingival envelope flap has been
created to expose the furcatlon. 8, Sectioning of the rooth with a taper
diamond burr on a high-speed handpiece. C, Horizontal leverage with
an elevator.
point (Fig. 201- IOB). The tooth may be sectioned in a
straight fashion or slightly oblique through a developmental
groove, if present. 47
After sectioning, and some initial loosening of the two
fragments with a luxator, a dental elevator can be used for
horizontal leverage (Fig. 201-1 OC). The elevator is intro-
duced horizontally between the two segments of a two-
rooted tooth, rotated through a small angle, and held for a
few seconds, allowing the periodonlal fibers to stretch.
Gradually, the tooth is delivered by progressive tearing of
periodontal fibers and leverage.
The mandibular first molar is a large tooth. To better
expose the furcation of the root, and to be able to insert
the dental elevators or luxators more easily, an alveolotomy
can be performed.
Surgical Extraction of Three-
Rooted Teeth
These teeth include the maxillary fourth premolar and
the maxillary molars. They may be difficult to remove
because of their size and the poor visibility in the caudal
part of the oral cavity. To achieve maximum visibility, the

animal is placed in dorsal recumbency with the mouth held
open with an oral speculum (see Fig. 201-1 ).
Surgical Extraction of a Maxillary
Fourth Premolar
The maxillary fourtb premolar is a large tooth with two
long buccal roots and one slightly shorter but slender pala-
tal root. If no periodontitis is present, it is advisable to
remove some of the buccal alveolar bone after a buccal
triangle mucogingival flap has been raised. In designing the
flap, care is taken not to damage the parotid papilla and the
infraorbital blood ve.:;sels and nerve. The intrasulcular inci-
sion is extended mesiaUy for about 2 mm if there is
enough space between the third and fourth premolar. The
distal incision is extended for 3 to 4 mm into the sulcus of
the first molar. One perpendicular incision is made on the
mesial aspect in the gingiva extending into the oral mucosa
(Fig. 201 - llA). The incision is perpendicular, rather than
at a divergent angle, to avoid the infraorbital neurovascular
structures. The mucoperiosteal triangle flap is elevated with
a periosteal elevator and reflected , exposing the buccal al-
veolar bone (Fig. 201- 1'18). The alveolar bone overlying
the two buccal roots is partially drilled away and the furca-
tion is exposed. The gingiva on the mesial aspect is re-
flected to expose the furcation between the mesiobuccal
and palatal roots.
The maxillary fourth premolar is first sectioned between
the two buccal roots, then in between the mesiobuccal root
and the palatal root in the same way as described for two-
rooted teeth. It is important to be familiar with the tridi-
mensional morphology of this tooth to perform the section-
ing correctly (Fig. 201-llC). The two buccal fragments
are then removed separately, according to the technique
described for two-rooted teeth. The palatal root can be seen
better if some of the furcation bone between the mesiobuc-
cal root and the palatal root is removed; subsequently, the
luxator is introduced on the mesial and distal aspects at a
60° angle to the hard palate to loosen this root (Fig. 201-
11D). Care is taken not to penetrate the maxillary recess or
the infraorbital canal. After the extraction, sharp bone
edges are removed, the alveoli are inspected and flushed,
and the triangle flap is repositioned and sutured. If the
reason for extraction was a periapical abscess causing a
sinus track, one may opt to leave the extraction wound
partially open to promote drainage.
Surgical Extraction of a Maxillary First
Molar
The maJtillary first molar is a large tooth with two long
buccal roots and one shorter, conical palatal root. A buccal
triangle flap or envelope flap can be used to facilitate
extraction. In designing the flap, care is taken not to dam-
age the zygomatic papillae. The maxillary first molar is
first sectioned b etween the palatal root and the two buccal
roots, then between the two buccal The three frag-
ments can be removed separately, according to the general
principles outlined before. Flap closure can be challenging,
and often the wound edges are only approximated if ten-
sion-free closure cannot be achieved.
Exodontics Z705
Surgical Extraction of a Maxillary
Second Molar
The maxillary second molar sometimes has fused roots,
resulting in one short, cone-shaped root. In this case, it is
fairly easy to loosen it and lift it out with a dental elevator.
If the three roots are present, they are short but curved,
making this tooth difficult to extract. Because the tooth is
so small, sectioning is difficult. It is more practical to try
to remove the tooth intact. Should one of the frac-
ture, it is removed with a root tip elevator.
SPECIAL CONSIDERATIONS
Deciduous Teeth
Extraction of deciduous teeth is often indicated for or-
thodontic reasons (inte rceptive orthodontics) and is per-
formed as soon as the necessity becomes obvious. The
roots of a deciduous tooth are close to the developing
crown of the permanent tooth. The root shape tends to be
proportionally slimmer and longer in the deciduous tooth
than in the permanent tooth. These two anatomical features
make it imperative that great care be taken in extracting a
deciduous tooth.
TI1e dental elevator or luxator and root tip elevator are
the primary instruments used to remove deciduous teeth.
The root should be completely but carefully loosened from
the periodontal ligament. It is rarely necessary to use ex-
tr.Lction forceps. Surgical extraction is occasionally indi-
cated, especially for deciduous canines. A small triangle
flap combined with a buccal alveolotomy greatly facilitates
the delivery of a persistent deciduous canine tooth and may
be preferable to simple extraction. 15
Fractured deciduous root tips may resorb,9 but often they
do not. They are retained in the alveolar bone and impair
normal eruption of the pennanent teeth.
Exodontics in the Cat
The preceding descriptions are based primarily on the
dog. Because of the smaller size of the roots, root tip
elevators are used as dental elevators in the cat These
instruments are used with great care; they are sharp, and
the bone plate between the nasal and oral cavity is thin.
Oronasal fistula formation is a possible sequel to the over-
zealous use of these instruments.
It is important to be fam iliar with the tridimensional
morphology of the teeth. Anatomical variations involving
the maxillary second and third premolars and the maxillary
first molar are common. 55 The maxillary second premolar
and first molar can have a single root, a fused double root,
or two fully formed roots; it is common for the normally
two-rooted third premolar to have a supernumerary root on
the palatal aspect. 55 The maxillary fourth premolar is a
large tooth, with two slender mesial roots and one wider,
conical distal root. Some of the buccal alveolar bone may
be removed after a buccal flap has been raised. This tooth
is first sectioned between the two buccal roots, then in
between the mesiobuccal root and the palatal root. The
2706 DentiStry

Figure 201-11. Selected of the extraction of a m:t>.allary founh

premolar (with the dog in dorsal recumbency). A. Venical incision
for creating the triangle ll;ap. B. The mucogingivnl triansle nap ha> been
raised. C. Demonstration on a specimen of the angle for '>CCilomng the
palatal root. D. Luxation of the palatal root.

three fragments are removed separately. The mandibular Extraction of All Premolars and Molars
first molar is a large tooth with a wide, large mesial root
with an oval cross-section; the distal root is slender and The extraction of all premolars and molar teeth is an ac-
round in cross-section and often caudoventrally angled. cepted therapy for chronic stomatitis not responding to

Figure 201 - 1 Z. End-stage feline odontocla\lic resorption lesion on the
mandibular founh premolar in a cat, which is a good indication for crown
amputation with intentional root retention. (From Lommer MJ, Verstraete
FJM: Prevalence of odontoclastic resorption lesions and periapical radio-
graphic le\iOn\ in 265 cases 11995 19981. JAm Vn Med Assoc 217:
1866. 2000.)
medical treatment. 19 In some patients, removal of the ca-
nines and incisors may also be indicated. The importance
of pain control and nutritional support for these patients
cannot be overemphasized.
When all premolars and molars in a quadrant are ex-
tracted, an extended envelope flap is made. The furcations
of multirooted teeth are exposed by removing some of the
alveolar margin bone, and these teeth are subsequently sec-
tioned and removed by a combination of luxation and ele-
vation. Horizontal leverage can be used between the sec-
tioned fragments of multirooted teeth. Bone prominences
are smoothed, the alveoli are flushed, and the flap is repo-
sitioned and sutured without tension. Feline gingiva is fria-
ble, especially if gingivostomatitis is presenr.
Crown Amputation with Intentiona l
Root Retention
Feline odontoclastic resorption lesions make dental ex-
traction in the cat particularly difficult because of the high
risk of root fractures. Root fractures with retention of the
apical fragment may result in persistent pain and complica-
tions such as osteomyelitis of the alveolar bone. Leaving
fractured root tips behind, in the absence of periodontal
and endodontic disease, was acceptable. 10 Pre-extraction ra-
diographs are critical in case selection; teeth with advanced
Exodontics 2707
root resorption, without periodontal or endodontal lesions.
are good candidates for crown amputation with intentional
root retention (Fig. 20 I - 12). The procedure is perfom1ed
by raising a small gingival or mucogingival envelope flap
and amputating the remaining crown with a small round
diamond burr on a high-speed handpiece. The alveolar
margin is subsequently smoothed with the same instrument,
the surgical site irrigated, and the envelope flap closed. A
tooth with a feline odontoclastic resorption lesion that has
a well-defined periodontal ligament space, bone loss due to
periodontitis, or a periapical lesion evident on
is extracted in toto.
COMPLICATIONS
Root Fracture
Fracture of a root is a common complication of poor
surgical technique. Although a retained root tip may go
unnoticed and may undergo resorption in the absence of
infection, n persistent infection and periapical disease, ostei-
tis, sinus fom1ation, and chronic nasal discharge are com-
mon sequelae. After extraction of a tooth, the root tip is
carefully inspected. An intact root tip is rounded and usu-
ally has soft tissue attached to it at the apex. A root canal
is not visible. If at all in doubt, radiography is indicated.
Substantial root tip fragments can be loosened and lifted
out with dental elevators. Smaller fragments can be re-
moved with root tip elevators or root tip picks (see Fig.
20 1-5). An endodontic file can be wound into the root
canal to secure the fragment while elevating it and sub e-
quently to lift it out. 3 Root tip forceps are also available
( ec Fig. 201-78). Good lighting, irrigation, and suction
are essential for good visibility. If necessary, a mucogingi-
val flap can be raised and an alveolotomy performed to
expose a root fragment. Alternatively, small root tips can
be drilled out under constant irrigation (pulverization, at-
om ization)9; however, this technique can result in consider-
able iatrogenic trauma and is not recommended. Leaving
root tips behind may be acceptable in exceptional circum-
stances (e.g., half-resorbed root tips, without periapical le-
sions and deeply embedded in bone, especially in cats, or
patients at anesthetic risk).
Hemorrhage
Hemorrhage may be a problem in patients with impaired
hemostasis. The mucosal bleeding time test is a practical
method for screening for blood coagulation disorders. 26 If
the history indicates the possibility of a clotting disorder,
more specific tests are indicated. An alveolus normally fills
up with a blood clot that is gradually replaced by granula-
tion tissue and covered by epithelium. 22 If prolonged hem-
orrhage occurs, the empty alveolus may be plugged with
oxidited cellulose; which is resistant to infection.K. 11
Hemorrhage may be severe if the infraorbital, major pal-
'Surgiccl, Ethicon, Somerville. N.J.
2708 Dentistry
atine, or inferior alveolar artery is lacerated during an ex-
traction procedure. The importance of being familiar with
the surgical anatomy of the oral cavity cannot be overem-
phasized. Knowledge of adjacent anatomical structures and
careful technique are essential in avoiding iatrogenic vascu-
lar trauma.
Delayed Wound Healing and
Infection
Wound healing in the oral cavity, including the healing
of extraction wounds,22 is generally rapid and uncompli-
cated because of the excellent blood supply. However, care
is taken not to traumatize the oral soft tissues and espe -
cially the wound edges. Electrocoagulation is used judi-
ciously, if ever. Soft tissues must be retracted and pro -
tected during osseous surgery. Delicate instruments and
fine suture material are conducive to sensitive tissue han-
dling. Delayed wound healing is anticipated with systemic
diseases such as diabetes, after long-standing corticosteroid
treatment, in animals undergoing chemotherapy, and if the
surgical site has previously been irradiated. 4 1
A nonhealing alveolus and alveolar osteitis (or so-called
dry socket) are rarely seen in the dog and cat. 9· 49 Foca l
fibrinolysis is the major cause of premature blood clot loss,
which leads to this common complication in humans.'· 56
This condition is treated by surgical curettage; infection
generally does not pose a major problem. Antiseptic
mouthwash and suitable antibiotics can be used in selected
cases .
Oronasal Fistula
This complication can be caused by the avulsion of a
part of the alveolar wall during extraction of a maxillary
canine tooth or by periapical bone destruction due to a
chronic inflammatory process. After removal of a maxillary
canine, it is. important to check whether a communication
with the nasal cavity has bee n created, evidenced by ipsi-
lateral nose-bleeding. Persistent oronasal fistula can be cor-
rected by various methods; however, good surgical tech-
nique during the extraction procedure largely prevents this
complication. 2.s
Mandibular Fracture
This is a rare complication caused by overly forceful
technique. Special care is taken in this respect in geriatric
patients, in which thinning of the mandible as a result of
hori1.0ntal bone loss may occur. The palm of the non -
instrument hand can be used to support the mandible when
force is applied to a tooth during extraction. 16
Alveolar Margin Resorption
Alveolar margin resorption is a major concern in human
oral surgery; it may interfere with the patient's denture-
bearing ability and the feasibility of using implants. 4 1 Vari-
ous synthetic substances with osteoconductive properties
have been used in humans for alveolar margin preserva-
tion. Similar products have been placed in extraction sites
of dogs with good results. 7• 14
Functional Complications
Functional complications, such as tilting or drifting of
adjacent teeth, as commonly seen in humans, do not seem
to occur in the dog and cat. When the mandibular canines
are extracted. the tongue may hang out of the mouth at
times. 16• ;o Conversely, the upper lip may be caught be-
tween the mandibular canine and. the palate after the ex-
traction of a maxillary canine. Extraction of incisors, ca-
nines, and molars may result in a traumatic occlusion of
the premolars and associated soft tissue trauma.
Other Complications
A wide variety of other complications that can generally
be attributed to poor technique may occur. Instrument slip-
page is common, especially when luxators are used, and
may result in soft tissue laceration. The orbit may be trau-
matized if this complication occurs during the extraction of
a maxillary fourth premolar or molar. Salivary may
also be traumatized by accidental laceration or incorrectly
planned mucogingival flap design. Care is taken not to
introduce a root fragment into t he nasal cavity or into the
mandibular canal. Mandibular canal perforation may result
in he morrhage, as previously mentioned, and trauma to the
inferior alveolar nerve. Damage to adjacent teeth may re-
sult from the incorrect use of the horizontal leverage tech-
nique.
References
1. Alexander RE: Dental extraction wound management: A case against
medicati ng po8tel\traction so<:kets. J Oral Maxi/lofac Surg .511:538,
2000.
2. Andreasen JO, Andreasen FM: Textb()()k and Color Atlas of Trail·
matic Injuries to the Te.eth, 3rd ed. Munksgaard, Copenhagen, 1994.
3. Bath M, Pernavec JC: Basic exodontia. In Fonseca RJ (ed): Oral and
Maxi/lcfacial Surgery. WB Saunders, Philadelphia. 2000, 207.
4. Black AP, et al: Bacteremia during teeth cleaning and
extraction in the dog. JAm Anim flosp Assoc 16:611. 1980.
5. Callender DL: Antibiotic pr(lphy1axis in head and neck oncologic
surgery: The role of gram-negative coverage. lnt .l Antimicrob Agents
12(Suppl l ):S21. 1999.
6. Costello BJ, ct al: Complicated exodontia. In Fonseca RJ (ed): Oral
and Maxilfofacial Surgery. WB Saundern, 2000, p 229.
7. Cranin AN, et al: The use of a particulate, microporous, .;alcified
copolymer as a ridge main tenance device in dogs. J Vet Dent 12:53,
1995.
8. Dineen P: Antibacterial activity of oxidi7ed regenerated cellulose.
S urg Gynecol Obsret 142:481, 1976.
9. Dom AS: Dental extr.1ctions and complications. In Slatter D (ed):
1'e.xtbook of Small Animal Surgery, 2nd ed. WB Saunders, Philadel-
phia, 1993, p 2326.
10. DuPont G: Crown amputation with intentional root retention for ad-
vanced feline lesi(lns- a clinical study. J Vet Dent 12:9,
1995.
 Exodontics 2709

I I. Durack OT: Prevention of infective endocarditis. N Engl J Mt.'d 332: 34. PeterAon U: Principles of complicAted exodontia. /11 P eterson U , et
38, 1995. al (cds): Conrempora.ry Oral and Marilfofacial Surgery, 3rd ed.
12. Eisner ER: Surgkal tooth extraction in two of impacted. abnor- Mosby - Year Book, Philadelphia. 1998. p 17!!.
mally developed teeth. J Vet Denr 6: 17, 19R9. 35. Plata RL, et al: Inten ti onal retemi on of vital submerged roots in dogs .
I3. Field EA, ct a!: The removal of an impacted maxillary canine and Oral Surg Oral Med Oral Parhol42 :100, 1976.
associated dentigerous cyst in a Chow: A cuse report. J Small Anim 36. Ratcitschak KH, et al: Color Atlas of Dental Medidne: Periodonw/-
Prac:t 23: 159, 19K2. 01/J, 2nd ed. Georg Thieme Vtrlag, Stuttgart, 1989.
14. Gauthier 0, el al: A new injectable calcium phosphate biomaterial for 37. Rodrigo JP, et al: Comparison ()[ three prophylactic antibiotic regi-
immediate bone filling of extraction A preliminary study in mens in clean-contaminated head and neck surgery. Head Neck 19:
dogs. J Period<mtol 70:375, 1999. · 188, 1997.
15. GorTel C. Robinson J: Periodontal therapy and extraction technique. 38. Ross DL: Orthodontics for the dog. Treatment methods. Vet Clin
Tn Crossley DA, Penman S (eds): Manual of Small Animal Denrisrry, Norrh Am Small Anim Pract /6:939, 19&6.
2nd cd. British Small Animal Veterinary Association, Cheltenham, 39. Silver JG, et al: Recovery and cleiiCance rates of oral
1995, p 139. following experimental in dugs. Arch Orai Biul 20:675,
16. Harvey CE: Tooth exttaction in and Compend Conlin C:duc 1975.
Pracr Vet 10:175, 1988. 40. Smi th MM: Lingual approach for surgical extraction of the mandibu-
17. CE, ct al: Antimicrobi al susceptibil ity of subgingival bacterial lar canine tooth in dogs and cats. J Am Anim liosp Assoc 32:359,
ftora in cats with gingivitis. J Vet Dent 12: 157, 1995. 1996.
18. Harvey CE. et al: Antimicrobial susceptibility of subgingival bacterial 4 1. Sullivan SM: The principles of exodontia: Simpltl
ll ora in dogs with gingivitis. J Vet Dent 12: 151. 1995. steps for safe extnlctions. Compend Comin Educ Dem 20:48, 1999.
19. Henne! P: Chronic gingivo-stomatitis in cats: Long-tcm1 follow-up of 42. AN. el al: Efficacy of preoperative decontamination of the
30 cases treated by dental extractions. J Vel Dem /4:15, 1997. oral cavity. Pla.,t Sur11 106:895, 2000.
20. Holmstrom SF:. et a!: V£•terinary Demal Techlliques-for rhr. Small 43. Summcrsgill JT, et al: Comparative of metronida:t.ole,
Animal Practitioner, 2nd ed. WB Saunden;, Philadelphia, 1998. clindamycin, chloramphenicol, cefoxitin, ticarcillin, and moxalactam
21. Howe GL: l'he ExtracTion of Teeth. John Wright & Sons, Bristol, inlll bone. Anlimicroh A;?ents Che.mother 21:601, 1982.
1961. 44. Ten Catc AR: Orallfisrology: Development. Structure, a;ul Fmu:tion.
22. RF. Hansen LS: A histopathologic study or extraction 5th ed. Mosby-Year Book., St. 1998.
wounds in dogs. Oral Surg Oral Med Om/ Patlwl 28:187, 1969. 45. Tenenbaum H, et al: Amoxicillin and clavulanic acid concentrations
23. Hupp JR: Principles of ac;epsis. In Peterson U , e1 al (eds): ConteTli{HJ- in gingival crevicular floid. J Clin Periodontol 24:804. 1997.
rory• Oral und Maxillofacial Surgery, 3rd ed. Mosby- Year Book, St. 46. Tholen MA: Veterinary nral surgery - ! . Vet Med Small Anim Cli11
Louis, 1998, p 69. 77:703. 1982.
24. Johnson JT, ct al: Comparison of versus clinda- 47. MA: Veterinary oral .'>urgcry - 2 . Vet M.ed Small A11im C/in
mycin in the prevention of infection in patients undergoing head and 77:907, I982.
neck surgery. Head Neck 19:367, 1997. 48. Tong DC, Rothwell BR: Antibiotic prophylaxis in dentistry: A review
25. Kapatkin AS, et al: Problems ass1x;iuted with basic oral surgical and practice . .I Am Dent Assoc 131:366, 2000.
techniques. Pro/Jl Vet Med 2:85, 1990. 4 9. Van Cauwelaert de Wyels S: Alveolar oste itis (dry socket) in a dog:
26. Marks SL: The buccal mucosal bleeding rime. J Am Anim Hmp A case report. J Ver Dent 15:85. 1998.
Assoc: 36:289, 2000. 50. van 1-'oreest A: Exodontia (tooth extraction in dogs). Eur J Compan-
27. Morgan JP, et al: Amimicrobial skin for the maxillofa- ion Anim Proct 3:35, 1993.
cial region. J Oral Maxillofac Surg 54:89, 1996. 51. FJM: Instrumentation and technique of removal of penna-
2R. Mueller SC, et a!: Perioper.nive antihiOLic prophylaxis in maxillofacial neot teeth in the dog . .f S Ajr Vel As.1oc 54:231, 1983.
surgery: Penetration of clindamycin into various J Cranio· 52. Venmactc FJM: Self-Assessment Co/or Rel•iew of \;eteri.mvy Den-
maxilloja.c Surg 27: 172, 1999. tistry. fowa Statt Univen.ity Ames, 1999.
29. Mumaw ED, Miller AS: The application of a frequency oscillation 53. Verstraete FJM , et al: Diagnostic value of full-mouth radiography in
method for tooth extrac ti on in dogs. Lah Anim Sci 25:228. 1975. cats. Am .I Vet Res 59:692, l998.
30. Norris LH, Doku HC: Antimicrobial prophylaxis in or.d surgery. Curr 54. Verstraete FJM. et a!: Diagnostic value of full-mouth radiography in
Opin Dent 2:85, 1992. dogs. Am J Vet Res 59:686, 1998.
31. Olson RA, et al: A comparative study of polylactic acid. Gelfoam. 55. FJM, Terpak CH: Anatomical variations in the dentition of
and Surgicel in healing extraction sites . Oml Surg O•·a/ Med Oral the domestic cat. J Ver De.m 14: 137, 1997.
Patho/ 53:441, 1982. 56. Vezeau PJ: Dental exuoction wound management: Medicating postcx-
32. PettlrAOn U: Principles of antibiotic thempy. In Topazian RG, Gold- rraction J Oral Maxillofa<: Sur8 58:531, 2000.
berg MH (eds): Oral and Maxillofacial Jnf ecrions, 3cd ed. WB Saun- 57. Walker CB, ct al: Gingival crevicular fluid leyels of clindamycin
ders, Philadelphia, 1994, p 160. compared with its minimal inhihitnry concentrations for periodontal
33. Peterson U : Annamentarium for basic oral surgery. /11 Peterson U, bocteria. Antimicrob Agents Chem01her /9:867, 1981.
er al (eds): Contemporary Oral and Maxillofacial Surxery, 3rd ed. 58. Withrow SJ: Dental extraction as a probable cause of septicemia in a
Mosby-Year Book. St. Louis, 1998, p 84. dog. JAm Anim llosp Assoc 15:345. 1979.