Because of my area of interest, it gives me great pleasure to see the article, ‘Prevalence and nature of dentoalveolar injuries among patients with maxillofacial fractures’ published in this issue by Soukup and others (2013). This excellent article documents findings that we all suspected were true. For example, it is not surprising that young animals and males are over-represented, as they are in the case of human trauma victims. Maybe this confirms that the behavior of young men is dictated by their biology – they can't help it!
More seriously, this article also highlights the need for comprehensive oral examination, supplemented with radiography, for the trauma case. It is important to realize, however, that this principle has a much wider implication. A thorough, meticulous oral examination is required for all patients with suspected oral/dental disease. Oral/dental diagnosis and treatment planning based solely on presenting signs results in misleading diagnoses and serious errors in treatment. A full oral examination under general anaesthesia as a minimum is required for accurate diagnosis and successful treatment planning. Moreover, radiography is nearly always required for accurate diagnosis, but also to perform certain procedures and assess the outcomes.
It is my opinion that the procedures for oral/dental examination are not adequately taught in our veterinary undergraduate programmes, which explains why so many conditions are missed. Radiography of oral/dental structures requires specific techniques (intraoral bisecting angle, intraoral parallel and others) which, again lamentably, are not a routine part of the veterinary curriculum. It is not surprising that so much disease is not detected until the pathology is severe. Yet oral health is vitally important for the general health and well-being of dogs and cats.
Not only is the diagnosis of oral/dental conditions poorly taught but to confound the problem further, oral conditions and diseases are intrinsically a diagnostic challenge. Firstly, irrespective of the reason for which the animal is presenting in many, if not most cases, the patients have gingivitis and often an associated periodontitis. In other words, it is common that several disease conditions present simultaneously. Secondly, clinical signs are rarely specific, i.e. halitosis, changes in eating patterns, dysphagia, are indications that there may be a problem in the oral cavity, but they are not specific for a particular disease. Thirdly, owners often fail to recognize that there is a problem or that their pet is in discomfort or pain until the disease condition has reached an advanced stage or when it has been treated and they then notice a difference. For example, halitosis generally develops slowly and owners become used to the “dog breath”. Changes in eating habits usually manifest slowly and progressively so that by the time the owner brings their pet for a particular problem the underlying cause may have been present and unnoticed for some considerable time. Finally, manifestations of disease are often discrete and are often not detected during a conscious clinical examination and even if they are detected, general anaesthesia is required to fully evaluate the extent of the pathology.
In their excellent article, Soukup and others (2013) draw a distinction between severe and non-severe injuries. Severe injuries require emergency treatment (within one to four hours if possible) for the affected tooth/teeth to be maintained. This distinction is justified in the case of traumatic lesions, but it must be remembered that non-severe injuries also need treatment or they will lead to chronic inflammation and pain. However, with non-traumatic disease the distinction between severe and non-severe is blurred because of the stage the disease has often reached before presentation. For the reasons just described disease progression can be advanced before the animal is presented for investigation.
In summary, a full oral and dental examination, including dental radiography, under general anaesthesia is required for diagnosis, to evaluate the extent of disease and to plan treatment. In my own specialist dentistry and oral surgery practice, it is common that an animal is referred for one problem and several others (sometimes more detrimental to the well being of the animal) are detected. The importance of a full oral examination under general anaesthesia cannot be underestimated. It should be performed for all animals with suspected oral disease.
Dentistry encompasses conditions of all structures of the oral cavity, namely teeth (hard tissues and periodontium), oral mucosa, salivary glands, jaw bone etc. Some conditions can be managed successfully in general practice and some need referral to a specialist for treatment. The general practitioner needs to recognize the conditions, be able to perform a full diagnostic work-up, realize the clinical significance of the findings and institute treatment (in-house or referral) as requested.
The diagnostic workup for suspected oral/dental disease is identical for all cases and is designed to detect underlying and often not immediately apparent, pathology. Conscious examination will only detect gross abnormalities, e.g. complicated crown fracture, mass etc. Examination under general anaesthesia evaluates soft and hard tissues of the oral cavity. Each tooth should be investigated for evidence of periodontal disease (gingivitis scoring, measuring probing depths, investigating furcation defects etc.) as well as hard tissue abnormalities e.g. fracture and/or caries in the dog. The procedure for oral examination is systematic and identical whatever the presenting signs. All findings need to be recorded. A completed dental chart and additional notes is ideal. In most cases, radiographs are indicated in areas where abnormalities have been detected. To accurately visualize teeth and associated structures without superimposition of adjacent structures, intraoral radiography is needed. The techniques for this are specialized and need to be taught and practiced. Courses are available in several places in the UK and attendance at a practical course is a wise investment. Similarly, purchasing a dental X-ray unit is a good investment. Digital X-ray technology has improved and become cheaper over the last few years making this equipment accessible to the general practitioner and removing the need for messy X-ray developing procedures. The prevalence of dental/oral disease amongst our pets, particularly as the population ages, means that any financial investments can be recovered quickly.
Soukup and others (2013) discuss the under-reporting of dental trauma when the examinations are performed by general clinicians rather than dental specialists. They cite a recent study by Bonner and others (2012) that finds a staggering disparity of 6.0% as against 71.4%. While there is no similar data for non-traumatic disease my belief is that the findings would be similar.
Expanding from the trauma studies detailed by Soukup and others (2013) to general medicine, the importance of oral and dental health to the general well being of our pets is often demonstrated in my specialist practice by the number of owners who tell me, following treatment, that their pets have become “like they used to be when they were younger”. In order for our profession to continue to improve in protecting and improving the oral and general health of our patients I believe two things are required. First opinion clinicians in general practice need to ensure that they have adequate training and are suitably equipped with dental diagnostic tools, from periodontal probes to X-ray machines. Secondly, and perhaps most importantly, the curriculum in our veterinary undergraduate programmes needs to include practical training in dental and oral diagnostics.