Mandibular bone cyst?

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Tue, 16 Oct 2012 17:56:16 GMT

[quote user="Pynadath George"]Generally (obviously depending on size) it would be excisional biopsy,[/quote]

Therein lies your error. I know little of human tumours but I can assure you that in the cat or dog or horse simple removal of the grossly visible soft tissue mass could be totally inadequate and might only make matters worse in the long run.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 17:07:38 GMT

[quote user="Evelyn Barbour-Hill"]

Hardly a big deal. Personally I'd rather have an additional quick GA and have my suspicious lesion properly biopsied first, than have a dentist guddling about in the abnormal tissue that later proved to be neoplastic.

[quote user="Pynadath George"]the one radiograph that's present I wouldn't think of neoplasm at all.[/quote]

But then as you have yourself said you know little of veterinary dentistry.

New graduates and all sorts of people come to this forum for advice. It's desirable that it should be good advice.

[/quote] Generally (obviously depending on size) it would be excisional biopsy, so no remaining suspicious tissue would be left behind to "guddle about" in. People also come in this forum for a variety of reasons, including to discuss topics. Not just for advice or to provide advice. obviously if you are providing advice it should be good. However in this case I'm pretty sure with such little info no one can provide much except to ask for more clinical info.

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Tue, 16 Oct 2012 13:42:39 GMT

[quote user="Pynadath George"] However we often, for humans anyway, provide this sort of treatment and biopsy at the same time. Then review biopsy and if sinister treat accordingly[/quote]

Well, maybe human oral neoplasia is different from canine.

[quote user="Pynadath George"]provide surgery twice.[/quote]

[quote user="Pynadath George"]the one radiograph that's present I wouldn't think of neoplasm at all.[/quote]

But then as you have yourself said you know little of veterinary dentistry.

New graduates and all sorts of people come to this forum for advice. It's desirable that it should be good advice.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 13:14:58 GMT

Granted its best to diagnose before treatment. However we often, for humans anyway, provide this sort of treatment and biopsy at the same time. Then review biopsy and if sinister treat accordingly. If not you would leave accordingly rather than provide surgery twice. It would be different if It was a major surgery but Perio surgery is really minor and just opening up and cleaning and suturing back. Obviously we have too little clinical info to go on as the one radiograph that's present I wouldn't think of neoplasm at all. A photo would be good for basic info in this case.

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Tue, 16 Oct 2012 12:35:45 GMT

[quote user="Pynadath George"] Hi Evelyn, I would suggest diagnosis of neoplasm (cutting a sample) and periodontal surgery could be performed at the same time. You could elevate a flap cut out any soft tissue sample. Directly visualise any cause for periodontal probs which you could remove at the same time. And close up. Could this be a possibility?

[/quote]

Aaaargh! No! If there's neoplasia there then faffing about surgically in the area could makes things far worse. Could be disastrous. Oncologists might put it more elegantly but it's a fairly basic principle: get a biopsy and a diagnosis before you start messing things around.

[quote user="Pynadath George"]On another note how did you determine for sure there was a fractured tooth?[/quote]

I didn't. It looks very much to me that 305 has a root fracture, but as I said that could be artefact.

[quote user="Pynadath George"]Evelyn, I was also suggesting this to be chronic generalised periodontitis. Not periodontitis from a localised lesion of the 307. You mention this is unlikely, I would like to know why. [/quote]

Just 28 years of experience of dealing with these things. Call it "gut feeling" if you must, but it doesn't quite fit the pattern. We have only the one radiograph and a brief history to go on.

Of course I might be wrong. I sometimes am.

Re: Mandibular bone cyst?

Rajat — Tue, 16 Oct 2012 09:23:27 GMT

[quote user="Pynadath George"]Rajat You are absolutely correct about the costs of things. On this forum I am simply mentioning options that may or may not be possible as my experience in veterinary dentistry is limited. I'm just here looking at it from another angle. I'm sure Evelyn will let me know if something is possible or not in the veterinary world as there are obvious differences noted already.

[/quote]

Sure thing- I don't mean to disregard your opinions at all - just trying to high light things from a vet's perspective/how our daily best clinical endeavours are yanked on by chains in every direction - usually the biggest one being cost. Also forgot to mention given that dogs cant tell you if it hurts, and if we leave a tooth that requires daily care and the owner doesn't do it/we suspect they won''t do it and bring it back for repeat rads in 2 or 3 or 6 months to see if our clever perio surgery worked, then dog may suffer in silence as that tooth deteriorates, and a pain free mouth is more important obviously than saving one or 2 teeth.

So one also has to be a bit of a bloody mindreader in this profession sometimes.

Re: Mandibular bone cyst?

Rajat — Tue, 16 Oct 2012 09:18:19 GMT

[quote user="Evelyn Barbour-Hill"]Ho, but some of us do, Rajat. [/quote]

Of course, we are lucky enough to have more than one dental vet lurking on these boards, hence I said most of us and not all of us I wish we were taught more on some of thes eprocedures in college, maybe things are improving, I don't really know though.

Recently did my first crown shortening btw. Fiddly as it was in a geriatric cat's mandibular canines with tiny pulp cavities but went quite well and was quite rewarding! Looking forward to being able to offer this instead of extraction where appropriate.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 06:55:32 GMT

Rajat You are absolutely correct about the costs of things. On this forum I am simply mentioning options that may or may not be possible as my experience in veterinary dentistry is limited. I'm just here looking at it from another angle. I'm sure Evelyn will let me know if something is possible or not in the veterinary world as there are obvious differences noted already.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 06:51:06 GMT

Evelyn, I was also suggesting this to be chronic generalised periodontitis. Not periodontitis from a localised lesion of the 307. You mention this is unlikely, I would like to know why. I notice your in Bangor. My surgery is in Rhos on Sea. We are more or less neighbours!

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 06:45:55 GMT

On another note how did you determine for sure there was a fractured tooth?

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 06:44:56 GMT

Hi Evelyn, I would suggest diagnosis of neoplasm (cutting a sample) and periodontal surgery could be performed at the same time. You could elevate a flap cut out any soft tissue sample. Directly visualise any cause for periodontal probs which you could remove at the same time. And close up. Could this be a possibility?

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Tue, 16 Oct 2012 02:49:11 GMT

[quote user="Rajat"]

And in general practice we don't have the same dentistry skills that dentists possess at graduation - our dental teaching at university is somewhat limited shall we say Hence, most of us don't do many dental procedures other than scaling, polishing, and extractions. I am not including other types of oral surgery, but referring more to endodontic work.

[/quote]

Ho, but some of us do, Rajat.

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Tue, 16 Oct 2012 02:43:36 GMT

[quote user="Pynadath George"]Forgot to mention the 308 if a single root and single or max double canal it should be easy to negotiate and perform endodontic treatment.[/quote]

Of course it would. If that were indicated in this case. Though we should probably call it "308" as one cannot be sure from this radiograph that it is not a supernumerary tooth with a normal 308 distal to it.

[quote user="Pynadath George"]Would you guys not suggest surgical periodontal surgery first before extraction of this quadrant of teeth? This would allow direct visualisation of the pathology and curettage. If there was long term failure extraction at a later date is still possible. Just the loss of all these teeth would surely affect function and over eruption of the opposing dentition? Looking at the 307 again, the periapical radiolucency is likely nothing but trabecular bone spaces as the lamina dura is still intact for the tooth. There is bone loss indicated by the radiolucency in the bifurcation of the root of 307. So purely periodontal problems. 308 definitely looks as though widening of the lamina dura and periapical change occurring. Just some thoughts.[/quote]

Well, first of all the clinician needs to make cotton-pickin' sure that there is not neoplasia there. Since, as you say, you don't know much about veterinary dentistry yet you will have to take my word for it. But, assuming a reliable biopsy rules out neoplasia:

Yes, there's bone loss in the furcation of 307 as has been noted,(and there's periodontal bone loss in other sites too, as has been noted). It's unlikely that the problem here is simply arising from periodontal disease of 307; it's possible I suppose but the pattern just doesn't fit. The irregular lucencies ventral to 307 have no demonstrable connection to 307 but the larger does have demonstrable connection to the original lesion. One cannot possibly affirm confidently "so, purely periodontal problems" in this case (in my opinion).

Yes, of course that's a possibility (as long as neoplasia had been ruled out) , assuming the client wished to be referred to a specialist who could do it and felt he could ethically do it, and the client wished to pay for it. But the original poster wanted, I think, some practical suggestions as to how to proceed in the particular circumstances. Also, I'm fairly sure that you would be extracting 305 anyway, because it has a root fracture. Also, it's axiomatic that the success of periodontal surgery depends upon highly scrupulous oral hygiene, and that is something often hard to attain in a dog. Also: one has to ask, why? It is not important to keep this set of premolars, even if they are normal, which in this case they are most certainly not. I"d love to raise a flap and do clever things if this case were mine; but my professional ethical conscience would probably get the better of me.

[quote user="Pynadath George"]Just the loss of all these teeth would surely affect function and over eruption of the opposing dentition?[/quote]

No. Not remotely and in no way at all.

Re: Mandibular bone cyst?

Rajat — Tue, 16 Oct 2012 02:00:50 GMT

[/quote]

Well for owners who can afford to go to a Vet dentist for another GA to have periodontal surgery done I am sure the tooth can be saved in the immediate future and it may be an option but even then, personally I'd want to take 307 out because the distal root has lost a significant amount of bone and is adjacent to the swelling, so undoubtedly bone around there is not healthy. Home care is often limited and all too often the willingnes fades after a few months and is not as good as is needed to keep these teeth healthy. Additionally, I am no dentist, but I am wildly guessing that open root planing and some kind of tissue regeneration/allograft/synthetic material to promote bony repair would be needed to save this tooth. All this adds costs, and not surprisingly, most clients would opt for extraction rather than saving one tooth.

Costs drive a large part of the decisions in this field, as does the fact at every dental procedure the animal is anaesthetised, in addition to the small risk this poses, it is a greater investment in time and emotions on the clients part. Hence they are more reluctant to have several GAs or procedures requiring repeated monitoring (eg Xrays under GA in the future) and potentially a much larger bill that the insurance won't cover.Some do go for it though, especially when the canine teeth are involved.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 01:01:01 GMT

Forgot to mention the 308 if a single root and single or max double canal it should be easy to negotiate and perform endodontic treatment.

Re: Mandibular bone cyst?

Pynadath George — Tue, 16 Oct 2012 00:58:54 GMT

Would you guys not suggest surgical periodontal surgery first before extraction of this quadrant of teeth? This would allow direct visualisation of the pathology and curettage. If there was long term failure extraction at a later date is still possible. Just the loss of all these teeth would surely affect function and over eruption of the opposing dentition? Looking at the 307 again, the periapical radiolucency is likely nothing but trabecular bone spaces as the lamina dura is still intact for the tooth. There is bone loss indicated by the radiolucency in the bifurcation of the root of 307. So purely periodontal problems. 308 definitely looks as though widening of the lamina dura and periapical change occurring. Just some thoughts.

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Mon, 15 Oct 2012 22:25:54 GMT

The original poster said she probed but couldn't find any tracts. I think there is a fine tract on the radiograph from original lesion to one of the lucencies, but if the OP could not get a fine probe (I don't know what she used) into it, what would be her chances of getting a fine gp point into it? Apologies if you meant to try the gp point probe somewhere else....... but then I'm not sure where exactly you do mean to try it.

What's your interpretation of the other abnormalities?

Re: Mandibular bone cyst?

Rajat — Mon, 15 Oct 2012 22:07:43 GMT

Hi Pynadath, Thanks for the offer I will take you up on it Interesting background, what did your study show by the way (??sorry folks it is an innocent q at the risk of starting another nuclear BARF vs Kibble war...!)

Comparative medicine is always interesting, and good to share experiences/knowledge with colleagues from medicine/dentistry. It's amazing sometime how little our medical professional colleagues seem to know about what veterinary surgeons do ..! The more we share with each other, the better IMHO.

Re: Mandibular bone cyst?

Pynadath George — Mon, 15 Oct 2012 19:58:21 GMT

Hi Raj If you pm me your address I can send you some free from my surgery. I should have said you don't need purulence just swelling. My experience in animal dentistry is very limited. I did my undergrad study on dog teeth and the oral hygiene status differences in kibble, can and barf food. I have since had an interest.

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Mon, 15 Oct 2012 17:55:03 GMT

[quote user="Pynadath George"]I can't determine the system to your canine teeth.[/quote]

I'm not sure what you mean.

Can I help? I'm assuming you are familiar with the modified Triadan system.

Re: Mandibular bone cyst?

Bob Russell — Mon, 15 Oct 2012 17:48:14 GMT

[quote user="Pynadath George"]I can't determine the system to your canine teeth. However there seems peri apical and periodontal radiolucencies present. If there was buccal swelling with purulence, it would have been a better idea to place a radio opaque material like rct gutta percha material into sinus and take another X-ray. This will help diagnose if it's peri apical or periodontal in origin.

[/quote]

I assume it is the numbering of dogs teeth that is confusing you! Human dentists only have one species to deal with we have many and they all have their own idiosyncrasies! Counting upper incisors in cattle has always been a bit of a favourite with me!

Virbac have good stuff on their website and this explains the numbering:

http://www.virbac-dentals.com/p-dentalspuben/display.aspx?srv=p-dentals&typ=pub&lang=en&cmd=view&style=styles/page2.xsl&select=PAGE[@ID$eq$PAGE_3]#

Re: Mandibular bone cyst?

Rajat — Mon, 15 Oct 2012 16:01:41 GMT

[/quote]

Hmm good idea, but not many of us= hardly any of us have endodontic material lying around the clinic. A tiny dental needle or insulin needle *may* work but obv it isn't as thin as gutta percha material which I am imagining looks like a paper point? No purulence was reported in the OPs post by the way - if you read it, she describes cutting into the swelling.

Thanks

Raj

PS may I ask how much small animal work have you done and for how long have you been involved with Vet dentists/dentistry? Are you doing some on a regular basis or is it an occasional interest?

Re: Mandibular bone cyst?

Evelyn Barbour-Hill — Mon, 15 Oct 2012 01:42:44 GMT

How did it turn out, Holly? Anything to report?

Re: Mandibular bone cyst?

Pynadath George — Mon, 15 Oct 2012 01:14:30 GMT

I can't determine the system to your canine teeth. However there seems peri apical and periodontal radiolucencies present. If there was buccal swelling with purulence, it would have been a better idea to place a radio opaque material like rct gutta percha material into sinus and take another X-ray. This will help diagnose if it's peri apical or periodontal in origin.

Re: Mandibular bone cyst?

Holly Norman — Tue, 07 Aug 2012 17:55:39 GMT

Thank you very much for the help- that's fantastic! This owner is particularly high maintenance and I think he'll probably opt for referral.