Dental Case Study: Archie—In the Oral Cavity, a Thorough Physical Exam Both Clinically and Radiographically Pays Off

Right and left facial skin lesions on presentation.

by Jan Bellows, DVM, DAVDC, DABVP

Signalment

Archie, a Jack Russell terrier, was 14 years old at the time of initial presentation to my office. He weighed 21.3 pounds and had a body condition score of 8/9.

History

The history I received from Archie’s caregiver and the referring veterinarian was that he developed a right-side swollen facial skin lesion several months after receiving professional dental scaling, polishing, and a molar extraction. Clindamycin was prescribed without effect after 10 days, followed by enrofloxacin, which clinically resolved the facial lesion for approximately three weeks. The lesion returned and was accompanied by a similar wound on the left side below the eye. Archie’s chew treats included nylone bones and deer antlers. Referral was recommended to a veterinary dentist.

Physical Exam and Diagnostics

In addition to large bilateral crusty bleeding facial lesions, my examination revealed significant plaque and tartar on nearly all of the dentition. Both the right and left maxillary fourth premolars were fractured. Because of tartar accumulation, it could not be determined whether the fractures had resulted in pulp exposure; however, the tentative diagnosis was bilateral complicated maxillary fourth premolar fractures with extension of osteomyelitis to the facial areas below Archie’s eyes.

Additional diagnostics, including preanesthetic blood/urine, chest radiographs, and electrocardiogram tests, were recommended and agreed on in that anesthesia would be needed to further evaluate Archie’s condition. Fortunately, all preoperative test results were within the normal ranges.

Preanesthetic medication was administered, followed by general anesthesia and intubation. Anesthesia allowed full-mouth, intraoral radiographs, revealing expected periapical lucencies surrounding the right and left maxillary fourth premolar teeth as well as unexpected pathology of the right and left clinically normal maxillary third premolars. There was apparent periapical lucency and enlarged root canal chambers of the right third premolar consistent with a nonvital tooth; the left third premolar also showed periapical lucency and a supernumerary root.

Diagnosis

My diagnosis was extension of infection from bilateral maxillary fourth premolar complicated fractures as well as periapical infections of the right and left maxillary third premolars secondary to endodontic disease.

Treatment

Treatment included preparing the skin lesions, removing the surrounding crusts and hair, and scaling and polishing all the teeth, followed by flap exposure and extraction of the maxillary right and left third and fourth premolars. Archie recovered without incident. Gabapentin and meloxicam were sent home after surgery. The prognosis is excellent.

Clinical appearance of Archie’s fractured fourth premolars.	Intraoral radiographs of the maxillary right and left cheek teeth.

Home-Care Instructions

The client was instructed to finish out the enrofloxacin she had at home and feed a softened diet for one week. The client was also advised to remove all oral chews that do not bend and was given a list of the Veterinary Oral Health Council’s accepted plaque- and dental-control products.

Outcome

Within two weeks, the facial lesions resolved, and hair began to grow over the lesions.

Conclusion and Comments

There is much that can be learned from this case.

Swelling and bleeding crusty skin lesions under dogs’ eyes most commonly occur from extensions of endodontic disease of the cheek teeth. In this case, the thorough dental scaling four months prior may have dislodged debris at the fracture sites, allowing oral bacteria to populate the pulp chambers and leading to periapical osteomyelitis. The most common tooth involved in these types of lesions is the maxillary fourth premolar. In this case, thanks to examination of intraoral radiographs, pathology of the clinically normal third premolars was also revealed.

Prepped lesions after surgery.

Often, veterinarians treat these lesions initially with antimicrobials, which result in temporary improvement. Antimicrobials do not treat the real problem—pulp exposure. Extraction in these cases is the treatment of choice. Root canal therapy can be provided with a guarded prognosis once the osteomyelitis has extended clinically under the eyes.

Prevention is as important to patient health as the other components of the oral assessment, treatment, and prevention (oral ATP paradigm). Archie’s lesions would have not occurred if he did not have access to deer antlers and hard plastic chew toys. Part of each patient history should include a discussion on diet and what the dog is allowed to chew on.

Jan Bellows, DVM, DAVDC, DABVP (canine and feline specialties), is in private practice in Weston, Florida. He is a frequent national and international lecturer on topics related to companion-animal dentistry. He is a past president of the American Veterinary Dental College and is currently the president of the Foundation for Veterinary Dentistry. He is a coauthor of the AAHA Dental Guidelines for Dogs and Cats (2010, 2013, and 2019) and the author of the books Feline Dentistry (2010) and Small Animal Dental Equipment, Materials and Techniques, Second Edition (2019).

Photo credits: Photos courtesy of Jan Bellows