Emergencies in veterinary dentistry and maxillofacial surgery
Dental trauma/dental fractures
Fractured teeth are painful, but rarely observed. Fractured teeth are found in approximately 27% of dogs and 10% of cats. Continuous licking, reluctance to chew and sensitivity in the affected area might indicate a fractured tooth, especially when the pulp is exposed. Although this condition is very painful, the animals do not show signs of pain and may behave normally and exhibit normal eating and drinking habits. When a fractured tooth is observed, both pain medication and a plan for definitive treatment is needed. Leaving fractured teeth untreated is not acceptable.
Deciduous teeth are very long and narrow and are prone to fractures. As with permanent teeth, exposure of the pulp leads to bacterial infection of the pulp and spread of the infection through the tooth apex into surrounding bone, causing damage to the successor, developing permanent teeth. To prevent development of periapical inflammation and subsequent damage to the permanent teeth in puppies, a fractured deciduous tooth should be extracted as soon as it is detected.
In dogs and cats with permanent dentition, depending on the nature of the fracture, treatments such as tooth restoration, vital pulp therapy, root canal therapy or tooth extraction may be indicated. Recent tooth fracture is considered an emergency if we want to save the tooth. Vital pulpotomy can help save fractured immature permanent teeth of young animals. It prevents pain and development of periapical disease and maintains vitality of a tooth allowing the tooth to continue its normal development. The same procedure can be performed on fractured mature tooth and is considered optimal if the fracture occured within the last 48 hours. The exposure of a pulp for more than 48 hours lowers the probability of a vital pulpotomy success and the tooth should be treated with standard root canal treatment that carries a high long term success rate, over 95%, or extraction, if standard root canal treatment is not possible or is declined by the owner.
Most oromaxillofacial fractures are of traumatic origin (car accidents, fights between dogs or falls from height – common injury in cats) but can occur also due to severe periodontitis or neoplasia causing pathologic fractures. Maxillofacial trauma causes discomfort and pain and can result in significant patient disfigurement. Other characteristic signs of jaw injuries are abnormal deviations of jaws (malocclusion) and abnormal movement and position of teeth. Non-specific signs include pain, epistaxis, ptyalism, blood-tinged saliva and reluctance to eat. Each patient with more severe head trauma should be firstly assessed for signs of hemorrhage and shock, upper airway obstruction, edema, cerebral injury and other accompanying soft tissue and/or skeletal injuries. Management of fractured teeth and/or jaws and/or soft tissue injuries are postponed until life-threatening problems, if present, are stabilized. Clinical examination and CT under general anaesthesia are necessary to determine precisely the nature and severity of the fracture(s).
The main principles of fracture treatment are restoring the occlusion and providing stable fixation obtaining a cosmetically acceptable and functional result. Non or mildly displaced fractures that are reasonably stable can be managed conservatively (stabilization with muzzle), while displaced or unstable fractures need to be treated using noninvasive stabilization techniques ((wire-reinforced) intraoral splints, rigid or semi-rigid maxillomandibular fixation) or invasive stabilization techniques (intraosseous wiring, miniplates and screws or external skeletal fixation), depending on the nature of the fracture(s).
Soft tissue trauma
Facial soft tissue wounds are most commonly caused by blunt or sharp trauma resulting in tissue devitalisation, contamination or infection. Treatment consists of wound debridement and lavage. Supportive pain and antibiotic management is necessary in these cases. Lip avulsion most commonly occurs due a car accident, when the soft tissue of the lips is pealed off from the bone. Soft tissues need to be cleaned and sutured to place as soon as possible.
As damage to the tongue can profoundly bleed the bleeding should be stopped as soon as possible, usually under general anesthesia and the tounge sutured. In general, bleeding in the oral cavity and in the nose may be also due to a variety of other causes, such as infectious diseases or blood clotting disorders (poisoning with rodent poisons), neoplasms, foreign bodies, trauma or advanced periodontal disease. If an animal is abnormally bleeding, it is necessary immediately visit a veterinarian.
Inability to open/close the mouth
Inability to open/close the mouth, most commonly associated with the pathology of the temporomandibular joint (TMJ) and other associated structures occuring due to trauma, neoplasia, foreign bodies or masticatory muscle myositis should always be considered an emergency as animals feel uncomfortable, are unable to eat and drink and feel pain.
TMJ fractures and luxations occur due to truma and are very often seen in a combination with other maxillofacial injurues, especially in cats. The most common clinical sign observed by the owners, which correlates with TMJ subluxation or luxation, is inability to completely close the mouth. Unilateral rostral and caudal luxations result in shifting of the mandible towards the opposite side of the luxation or toward the side of luxation, respectivelly. Fractures of the TMJ may or may not result in malocclusion, depending on the severity of displacement. The most commony used diagnostic modality for detecting the changes in the TMJ is computed tomography (CT).
TMJ subluxation usually does not require specific treatment other than soft food and restriction of oral cavity during healing. Reduction of acute TMJ luxation is attempted using closed techniques, while chronic luxation or intracondylar fractures usually require immobilisation (muzzle, maxillomandibular fixation) or surgical treatment approach (open reduction, condylectomy, coronoidectomy, zygomatectomy as needed).
Traumatic dentoalveolar injuries
Teeth are anchored within the jaws with the periodontal ligament and as such comprise the dentoalveolar unit. Subluxation, intrusive/extrusive luxation, lateral luxation and avulsion with or without alveolar bone fracture are specific injuries to the tooth-supporting structures sustained as a direct result of traumatic force. Timely recognition and prompt treatment of these injuries is important for optimal treatment outcome. Dental subluxations are rarely observed and typically resolve without treatment. Intrusive, extrusive, lateral luxations and avulsions are always considered an emergency, if we want to maintain the tooth. The teeth should be repositioned and temporarily splinted for approximately 2-4 weeks, depending on the type of the injury. Dentoalveolar trauma usually always leads to pulp necrosis as the neurovascular supply to the pulp is severed. Therefore additional treatment with root canal therapy will be needed either soon after splinting or at the time of splint removal. Splinting for the treatment of intrusive or extrusive luxation is utilized for approximately 2 weeks while the splint for the treatment of lateral luxation when associated with fracture of alveolar process should stay in place for approximately 4 weeks with endodontic therapy of affected tooth performed within 2 weeks of the splinting procedure. An avulsion is an injury in which the tooth is completely displaced out of the alveolus. The neurovascular supply to the pulp and periodontal ligament is completely severed and the entire root surface becomes exposed to the external environment. Immediate re-implantation (< 60 minutes) can save the tooth. The tooth should be stored in appropriate media (milk, saline, Hank’s solution) until the tooth is re-implanted. Splinting for 2-4 weeks is needed and in the case of mature tooth endodontic therapy of affected tooth performed 7-10 days after re-implantation. In immature permanent teeth the pulp has the potential to re-vascularize and may not need the root canal therapy after stabilization with the splint. The affected teeth treated with above mentioned methods need to be regularly monitored with dental radiography.
Sialocele is a localized cavity containing saliva occurring possibily due to trauma or infection of salivary gland tissue and/or ducts, although the cause in many cases remains unknown. It develops within the fascial planes of the throat, the orbit and the oral cavity. Ranula presents as a swelling on the floor of the mouth. Deviation of the tongue and problems such as difficulties in closing the mouth occur because the teeth occlude to the sialocele. Cervical or pharynegal sialoceles could provoke dyspnea because the expanding lesions tend to obstruct the airway, while zygomatic sialoceles displace the eye dorsally as the lesion is expanding in the floor of the orbit. Sialocele is usually not painful and the animals are generally not affected unless sialocele is pressing or occupying the repiratory airways causing difficulties to breathe. In these rare cases, a visit to the veterinarian is necessary, as the contents of the sialocele needs to be removed immediately. Further treatment, consiting of removal of the salivary glands associated with the sialocele, is done later.
Malocclusion and other selected conditions requiring intervention as soon as possible
Malocclusions due to abnormal positioning of a tooth or teeth (dental malocclusion) or due to asymmetry or other deviation of the jaws (skeletal malocclusion) are damaging the developing oral tissues (palate and gingiva) and are causing oral pain. A timely assessment, followed by an appropriate treatment can allow the animal’s jaws and teeth to continue growing to possibly reach an improved alignment, allowing the animal to use its mouth normally and to prevent damage to other parts of the mouth.
Unfortunately many oropharyngeal or sublingual tumors are diagnosed at the late stage when they are already advanced. For instance, tonsillar tumors or tumors of the caudal oral cavity usually remain unnoticed until clinical signs such as inability to eat or swallow and respiratory distress develop. These conditions require immediate help.
Burns occur due to biting the electric cables are most common in young animals. An immediate visit to the veterinarian due to the effects of an electric shock is needed. The extent of injury in the oral cavity is usually visible only after a few days after the injury. Chemical burns can result from ingestion of corrosive substances. Immediate rinse of the affected tissue with plenty of water and visit the veterinarian is necessary, but the extent of the lesion(s) is usually visible only after a few days.
If you have noted any problems with your animal, please consult your veterinarian.
Article by Ana Rejec