teeth (arrows) [B]. [B]. (arrows) teeth first and canine canine and incisor first gingiva at the maxillary maxillary the at gingiva margin and attached attached and margin maintain the gingival gingival the maintain effort should be made to to made be should effort (arrowheads) and every every and (arrowheads) of the gingivoplasty gingivoplasty the of used to bevel the edges edges the bevel to used diamond bur should be be should bur diamond canine (A). A A (A). tooth canine receive the linguoverted linguoverted the receive a "sliding board" to to board" "sliding a dorsally to serve as as serve to dorsally appearance, and wider wider and appearance, shaped (black lines) in in lines) (black shaped should be hour-glass hour-glass be should ing gingivoplasty gingivoplasty ing Fig. 2 Fig. a comfortable occlusion. ifaprocedurecanprovide quite lettingusconsultwith right,consider theownerandpettodetermine gingiva at first thecaninetoothbite themaxillary incisorandcanineteeth(Fig. isnot 3).When shouldbemadetomaintainthegingivalmargingingivoplasty andeveryeffort andattached (Fig.the linguoverted 2). A diamond bur should be used to bevel the edges of the be hour-glass shapedinappearance, andwiderdorsallyasa"slidingboard"toreceive to serve level bites.partial (base-narrow canine teeth), crowded or rotated teeth, and certain cross-bite, facialcuspids(base-widecanineteeth),lingual teeth andmay becategorized as:anteriorcross-bite, posterior When Bite's The Not Right! : issues in Dentistry an B A Class I can affect deciduous or permanent Class Imalocclusioncanaffectdeciduousorpermanent - result The correction of the linguoverted canine tooth (C). (C). tooth canine linguoverted the of correction shows improved occlusion (B). The 2-week postoperative examination showed showed examination postoperative 2-week The (B). occlusion improved shows Fig. 3 Fig. A Following gingivectomy/gingivoplasty (A), the post-extubation image image post-extubation the (A), gingivectomy/gingivoplasty Following soft tissuedefect. resultinggingivectomy/gingivoplastyshould The Maintenance oftheperiosteumwillenhanceepithelialization ofthe should beusedwithwater-cooling toavoidtissues. injury thermal focal areapredisposestobonyinjury. Likewise, thediamondbur tip. Prolonged pressurewiththeheat-generating ina instrument procedure to soft tissue, and efficient "light"useof theradiosurgery boneshouldbeavoided bylimiting tounderlying the injury Thermal and/or awater-cooled diamondburinahigh-speedhandpiece. canine teeth. linguoversion ofdeciduous mandibular procedures can be performed for tissue impediment(Fig. 1).Similar toeliminatemay beperformed thesoft tissue, and indentation from impaling the soft gingival margin causinggingivalirritation interfering withthediastemaof where thetipofcaninecrown is mandibular caninetoothlinguoversion inclinedplane.acrylic Inmildcasesof pulp therapy, orapplication of an teeth arecrown reduction andvital treatment of base narrow canine common dentalprocedures for option for this problem, the most Although tooth extraction is a viable known asbase-narrow canineteeth. mandibular caninetoothlinguoversion causeof theunderlying is considered teeth. canineandthirdincisor the maxillary interproximal space()between interdigitateteeth normally in the Gingivectomy/gingivoplasty may be performed with radiosurgery mandibular canineThe Heritable dentofacial deformity gingivectomy and gingivoplasty gingivectomy andgingivoplasty B d Hea d &N

and not treated (C). (C). treated not and was less severely affected affected severely less was mandibular canine tooth tooth canine mandibular (arrow) [B]. The right right The [B]. (arrow) soft tissue indentation indentation tissue soft with the hard palate and and palate hard the with resulting in interference interference in resulting class I malocclusion (A) (A) malocclusion I class dibular canine tooth from from tooth canine dibular - man left linguoverted a Mountain Cur dog with with dog Cur Mountain a 6-month-old, male male 6-month-old, a Fig. 1 Fig. B C A C eck S Photographs in in Photographs urgery

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fall Newsletter Chronic Nasal Discharge? Don't Forget To Rule-Out The Teeth!

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The Center for Veterinary Dentistry and Oral Dr. Mark M. Smith and Dr. KendallTaney are partners in the Center for Veterinary Dentistry and Oral Surgery Surgery offers cutting edge knowledge and state-of- established in 2006. Dr. Smith is a Diplomate of the the-art equipment to help you manage your patients American College of Veterinary Surgeons and theAmerican with dental and maxillofacial disease. Veterinary Dental College. He was Professor of Surgery and Dentistry at the VA-MD Regional College of Veterinary z Medicine at VirginiaT ech for 16-years before entering private practice in Root canal therapy 2004. Dr. Smith is Editor of the Journal of Veterinary Dentistry and co- z Restorations for caries and enamel defects author of Atlas of Approaches for General Surgery of the Dog and Cat. z Metal crowns to strengthen fractured teeth Dr. Taney is a Diplomate of theA merican Veterinary Dental z Surgery for neoplasms of the , & College and a Fellow of theA cademy ofVeterinary Dentistry. facial area She has practiced dentistry and oral surgery at the Center z Repair of maxillofacial fractures since 2006.S he is a 2002 graduate of the VA-MDRegional z College ofVeterinary Medicine. She completed her residency Correction of congenital palate defects at the Center and has also performed internships in both z Surgical extraction of diseased multi-rooted teeth general medicine and surgery, and specialized surgery. and impacted teeth Dr. Emily Edstrom is a 2010 graduate of the Colorado State z Therapy for oral inflammation University School of . S he completed a z Surgical management of diseases of the head rotating internship in small animal medicine and surgery at and neck VCA Veterinary ReferralA ssociates in Gaithersburg, MD. She is a member of theA merican Veterinary Dental Society. 9041 Gaither Road, Gaithersburg, MD u20877 Phone: (301) 990-9460 Fax: (301) 990-9462u www.centerforveterinarydentistry.com issues in Dentistry and Head & Neck Surgery Newsletter for referring fall 2013

DENTISTRY: SMALL MOUTHS, BIG HOLES: HEAD & NECK: Complicated ! A Closing Major Oral Defects. A Case Of The Sniffles! A Lymphoma is one of the most common malignant tumors to affect Unfortunately, often the diagnosis A B One of the more frustrating symptoms pets, dogs in veterinary medicine. Multicentric lymphoma is by far the most of oral neoplasia is made when the owners, and veterinarians experience is chronic nasal common form of lymphoma seen in veterinary patients, but other types lesion is quite large in relation to the discharge. Such a non-specific symptom can have many of lymphoma include mediastinal, gastrointestinal, and cutaneous. The size of the mouth. In fact, the lesion causes, and often many different medical therapies are cutaneous form has a predilection for epithelial tissue and often causes signs of can seem so large that all hope is lost attempted for treatment and/or to rule-out a disease chronic skin allergies, bacterial infection, or autoimmune disease. The and the owner is conveyed a grave process. Antibiotics may clear up the discharge, or main clinical signs in the early stages of prognosis based on the size of the C D antihistamines may reduce the amount, but generally B A disease include depigmentation, pruritis, lesion, regardless of the tumor type. symptoms return once medication is discontinued. Certain scaling, and hair loss (Fig. 1). These Oral reconstructive surgery tech- characteristics of the nasal discharge may help narrow skin lesions can progress to ulcerative niques allow closure of oral defects that down an etiology; for example unilateral mucopurulent plaques or tumors that do not respond to might seem intimidating or impossible nasal discharge may indicate a nasal foreign body, tooth systemic therapy. Fig. 1 Diffuse areas of to close based on the size of the defect Fig. 1 Malignant melanoma of the left mandible in root abscess, or nasopharyngeal polyp (Fig. 1). Unilateral a 13-year-old Dachshund dog (A). Note the caudal epistaxis could be a symptom of a nasal tumor or fungal B Epitheliotrophic lymphoma, also called cutaneous plaques, ery- following resection. The first step is mycosis fungoides, is a variant of cutaneous themia, and scaling of to make the diagnosis by incisional extent of the gross lesion. Intraoral dental radiographs disease. Dental radiographs can be a useful tool in any B lymphoma that has a predilection for the trunk (A) and chin or excisional biopsy. The next step showed lysis from the canine tooth to the mas- case of nasal discharge, at the very least to rule out mucosal tissue of the oral cavity and lip (B) were noted in this is to make every attempt to remove seteric fossa (B-D). a dental cause. Any teeth in the maxilla that show commisures (Fig. 2). It can present as dog with epitheliotrophic the entire lesion including tumor-free margins of the lesion. Oncologic surgery guidelines radiographic and/or visual signs of pathology should be a distinct nodule, as diffuse gingival lymphoma. recommend 1-2 cm of gross tumor-free tissue be included extracted (Fig. 2). If a tooth was truly the cause, the C nasal discharge should resolve over the next few weeks. hyperemia, or as crusting, non-pigmented A as part of the resected specimen. This parameter is more areas along the commisures. Palatitis and difficult to follow in the oral cavity of dogs because of Detailed views of the nasal sinuses can also be taken with palatal ulcers can also occur concurrently A the consistent small dental sensors and can identify destructive processes such as a tumor or fungal disease (Fig. 3). With the patient under with epitheliotrophic lymphoma. Although size of the mouth. A A this form of lymphoma is uncommon in 2-cm margin might general , a sinusotomy can be performed veterinary patients, it should always be include half of the through the oral cavity to retrieve samples from the Fig. 2 Lateral (A and considered in patients with a history of skull! nasal cavity for histopathology and culture. The biopsy result is the most important information when determining B) and rostral (C) pre- chronic skin infections and a new or recent B Therefore, operative photographs onset of gingivitis/. Obtaining a cause. We are all a little disappointed when we get a pragmatic Fig. 1 Radioopaque nasal foreign showing diffuse gin- a biopsy of the gingival tissue will help to B diagnosis of allergic or lymphoplasmocytic rhinitis, but at considerations body in a cat (A). This cat had gival hyperemia and distinguish epitheliotrophic lymphoma from B least the medical management can be further tailored to dictate goals that nasal discharge from the time the hypertrophy with a benign inflammation or other types of tumors the suspected disease process. still prioritize re- owner adopted it as an adult 10 spongiform texture in (Fig. 3). C this same dog. The moving the entire years previously. The foreign body owner reported that the Unfortunately, cutaneous epitheliotrophic tumor and maximize Fig. 2 Abscessed was buckshot that was removed from oral inflammation had lymphoma is usually of T- cell origin and, margins of normal maxillary 4th pre- the nasal cavity (B). The discharge therefore, carries a more guarded prognosis. appearing tissue tooth with resolved a few weeks after the foreign developed spontane- Fig. 3 Views of the buccal (A) The clinical course of epitheliotropic Fig. 2 CO2 laser soft tissue inci- around the tumor. periapical lucency. body was removed. ously over the last 2-3 and lingual (B) aspects of the lymphoma can be quite variable since sions are associated with decreased Maintaining function Dental radiographs months. resected mandible with malignant clinical presentation can vary from a hemorrhage and pain (A). The and providing accept- should be taken to melanoma. solitary nodule to diffuse, multicentric lesions present on the skin Fig. 3 Lateral (A extent of the lesion required total able cosmesis are also rule-out a dental and mucous membranes. Few studies have reported the long-term and B) and rostral (C) mandibulectomy with disarticula- major factors when determining the surgical plan. cause since routine outcome in dogs that have been treated for extranodal lymphoma; postoperative photo- tion of the TMJ (B). skull radiographs graphs following gin- The labial (buccal) mucosa provides lateral tissue therefore, the prognosis is somewhat limited. Most reports give a are unlikely to be sensitive enough for diagnosis. givectomies and biopsy that can be elevated and repositioned towards midline to aid wound closure following resection guarded survival time ranging from several months to a year with were performed. The of mandibular or maxillary tumors. In this case, the large oral melanoma required total chemotherapy. Cases of gingivitis or gingival hypertrophy may not gingiva was submit- mandibulectomy based on the bone lysis noted on dental radiographs. Skin juxtaposed with be so straight-forward. A thorough work-up and biopsy (Fig. 4) are the tumor also required resection ted for histopathology, A B C the keys for a proper diagnosis avoiding non- which revealed a low- minimizing mucosa available for A responsive symptomatic treatment that is grade epitheliotrophic A B wound closure. The procedure frustrating for the lymphoma. shown here maximized a patient, owner, B successful result with tumor-free and ! margins. The melanoma vaccine is recommended postoperatively C for all patients with oral malignant Fig. 4 Lateral (A and B) and rostral (C) Fig. 4 Views of the oral (A) and melanoma regardless of tumor Fig. 3 Sinus radiograph taken with a dental sensor in a cat with 2-week postoperative photographs showing cutaneous (B) wound closures fol- margin status. D an excellent response to chemotherapy (initi- lowing left total mandibulectomy. chronic nasal discharge. There is an appreciable difference in ated 1-week following surgery). The owner Note the wound closure for the com- opacity between the right and left sinus cavities (A). A sinusotomy reported that the cutaneous plaques and missurotomy that enabled exposure was performed (arrow) using an oral cavity approach to obtain a scaling had also resolved (D). for the TMJ disarticulation. nasal cavity biopsy (B and C).