Crown reduction or just extract?

RE: Crown reduction or just extract?

Rachel Perry — Sun, 03 Feb 2019 18:16:22 GMT

Kate, this is the article you probably remember reading:

Gracis M, Molinari E, Ferro S. Caudal mucogingival lesions secondary to traumatic dental occlusion in 27 cats: macroscopic and microscopic description, treatment and follow-up. J Fel Med Surg 2015; 17 (4): 318-328

It describes the proliferative lesions as well as more ulcerated foveas.

I tend to be less invasive with the young 6 month old cats, and perform odontoplasty tasking literally a whisker of the sharp enamel point off the upper 08 cusp tip(usually) and place a bonded sealant. I feel that the growth of the skull in this breed can help it to resolve with time.

In older cats I'm looking for a painful tooth somewhere- I think they chew slightly differently and the fact cats have no physical tolerance for that leads to abnormal contact and you can get the proliferative lesions. So excision and extraction becomes necessary. But you can then develop other lesions where you extract teeth and again alter the bite subtly. Client communication essential.

RE: Crown reduction or just extract?

Norman Johnston — Wed, 30 Jan 2019 13:00:09 GMT

There is a condition whereby a pyogranuloma lesion occurs in the area of the molar salivary gland that cats have medial to the mandibular carnassial tooth.
Removal requires a wide excision to ensure non-recurrence. Histo essential to differentiate SCC or similar

RE: Crown reduction or just extract?

Miriam Lodewyks — Tue, 29 Jan 2019 15:22:03 GMT

Thanks for the interesting case, Kate.

Fascinating reading (for a dental nerd like me, anyway).

Please keep us posted!

RE: Crown reduction or just extract?

Kate Richardson — Mon, 28 Jan 2019 20:42:11 GMT

Oh and I agree- hate the term scale and polish, ultrasonic decontamination sounds much better, or sub gingival decontamination?

RE: Crown reduction or just extract?

Kate Richardson — Mon, 28 Jan 2019 20:39:49 GMT

Thanks all, I’ll discuss the options with the client and will try to remember to report back to you all.

Theres another feline condition where they get ulcerated lesions in a similar location but lower, almost a polyp, can you remind what it’s called? Just so I can differentiate between the 2 in the future- my own cat had it, excised it twice, never recurred.

Really wish there was a feline dentistry qualification!

RE: Crown reduction or just extract?

Evelyn Barbour-Hill — Mon, 28 Jan 2019 20:19:52 GMT

I discuss the pros and cons with the owner and most I know would plump for extraction of the 108 – understandably. If not, there's nothing wrong with trying a mild crown reduction first (but as others have noted, if you go into the pulp you are faced with a fairly challenging case of miniature endodontics).

The 409 of course needs standard periodontal treatment according to the precise findings with it.

There are two factors in the cat that affect treatment plans: one is the small size of most of the teeth, relative to human hands and eyes,; the other is the greater difficulty of achieving oral hygiene at home. While we strive to do our best for the patient, we have to admit that these factors operate.

Incidentally, we are in need of a different term to "scale and polish" where no calculus is present, and quite probably no actual polishing will be done. "Scale" just seems quite wrong where we are removing only plaque, even though we will be using our ultrasonic scaler to do it. "Ultrasonic decontamination"? I dunno. Any suggestions?

"Scale and polish" to me always seems to suggest that cosmetic thing that people who are not very good at dentistry do to the crowns of the teeth after extracting "the bad ones".

RE: Crown reduction or just extract?

Bob Partridge — Mon, 28 Jan 2019 18:57:39 GMT

The bone loss around lower 1st molars is genuine & shows on your radiograph. The bone loss is related to the periodontal disease that is present locally.

I agree that a degree of malocclusion (often these have a degree of palato-version - inward tilting) of the upper arcade results in impact damage. This impact results in inflammation and enlargement of the tissues - leading to even more trauma....

I will often "disarm" the sharp points of the upper carnassials to take them out of impact. Some cases only require the enamel and a small amount of dentine to be removed. I use a small abrasive disk that I use for shaping composite restorations. I do require radiographic follow up at six months. In young cats the pulp chamber is wide and can be close to the surface - so care is required, sealant etc.

If in doubt - more certain is to extract.

The lower molars also need attention. S&P (yes I remove plaque everywhere I think it might be present!), I may also remove excess gingival tissues. In some cases the bone loss is so severe that extraction of the teeth may be required. These might be a candidate for Guided Tissue Regeneration - but I have not attempted this here.

All best

Bob

RE: Crown reduction or just extract?

Alexander Geddes — Mon, 28 Jan 2019 18:42:28 GMT

Hi Norman, the restoration covers the MTA you've placed but presumably you've got a bonded sealant over the rest of the exposed dentin in the same fashion as you would with the odontoplasty? To clarify your concern is with the inadvertent near/exposure of pulp in that procedure rather than your ability to seal exposed dentin?

RE: Crown reduction or just extract?

Kate Richardson — Mon, 28 Jan 2019 18:34:45 GMT

Interesting and completely the opposite of what I thought! Glad I asked now. So, probably extract 108 and monitor 409 (and 309).

So what causes the bone loss evident on the xrays? Or have I got that wrong and it's normal?

RE: Crown reduction or just extract?

Rob Davis — Mon, 28 Jan 2019 18:13:38 GMT

[quote user="Kate Richardson"]Ok you lost me at partial pulpectomy [/quote]

[quote user="Kate Richardson"]So am I right in assuming the ulcerated mandibular lesion is related to the periodontitis of 409? If so how does this occur? The 108 cusp wouldn't contact the mucosa if there was no lesion there, so again am I right in assuming 108 is exacerbating this rather than causing it?[/quote]

No, I think you have it the wrong way round: my feeling with these is that there is effectively a subtle malocclusion whereby the upper 08 cusps are positioned very slightly palatally. Very small malocclusions in cats tend to be more significant than in dogs. Any periodontal disease in the lower 09s is likely secondary (or even unrelated). Treatment relies on preventing the upper 08 cusp from causing trauma to the mandibular mucosa. As Norman said, extraction will be definitive, and I agree with his comment about the 07s, as these will sometimes cause a similar problem slightly rostrally. Crown shortening MAY help, but may not, and is not without it's own drawbacks.

If you want to treat it yourself, then extraction would probably be the best option. I suspect referral may result in extraction or attempts at crown reduction depending on whom you refer to!

RE: Crown reduction or just extract?

Kate Richardson — Mon, 28 Jan 2019 17:27:40 GMT

Ok you lost me at partial pulpectomy

So am I right in assuming the ulcerated mandibular lesion is related to the periodontitis of 409? If so how does this occur? The 108 cusp wouldn't contact the mucosa if there was no lesion there, so again am I right in assuming 108 is exacerbating this rather than causing it? Would help to understand as I see this not infrequently.

Given this cat is only 6months old, is it worth trying to save the teeth or is it pointless? I was thinking of just smoothing the cranial point on 108 crown that directly contacts the ulcer, but if you think this is pointless, I won't and will just advise extracting both. Or is it worth giving it time? Or would you advise referring him for specialist treatment? I'd be keen to 'fix' this myself if within my capacities

RE: Crown reduction or just extract?

Norman Johnston — Mon, 28 Jan 2019 17:03:25 GMT

No - because that pulp exposure is elective and designed to be deep enough to take a direct pulp cap of MTA plus a triple laminate restoration.
Success of elective crown reduction with vital pulp therapy according to Luotonen et al JAVMA, Vol 244, No. 4, February 15, 2014 -Vital pulp therapy in dogs: 190 cases (2001–2011) was around 92% from memory.
This was a 10 year study in Finland. Despite the success rate this is still the most technically challenging endodontic procedure.

RE: Crown reduction or just extract?

Rob Davis — Mon, 28 Jan 2019 16:35:31 GMT

[quote user="Norman Johnston"] A radiograph-guided odontoplasty followed by acid etched, dentine bonded sealant sounds attractive but how do you know you did not leave the cat with pain or sensitivity? A human patient comes back if they don't feel right. In a cat or dog you will never know. [/quote]

Fair point, but does this not apply to other treatments such as crown reduction with partial pulpectomy and vital pulp capping for linguoverted lower canines?

RE: Crown reduction or just extract?

Norman Johnston — Mon, 28 Jan 2019 16:08:11 GMT

Personally I like to remove the 108 and maybe the 107 to resolve this problem. Beware that in big cats (Maine Coon and the like) it makes sense to check the occlusion extubated before you close your flap.
Why remove? I like to sleep at night and not worry about being either close to or into the pulp when the cusp is reduced in height. A radiograph-guided odontoplasty followed by acid etched, dentine bonded sealant sounds attractive but how do you know you did not leave the cat with pain or sensitivity? A human patient comes back if they don't feel right. In a cat or dog you will never know.

RE: Crown reduction or just extract?

Rob Davis — Mon, 28 Jan 2019 15:12:41 GMT

I assume the mandibular lesion is exactly where the 108 cusp is sitting? I see these fairly commonly and they can be a pain. Resecting the lesion rarely works on its own as the upper 08 cusp continues to traumatise the mandibular mucosa. I have done crown shortening with some of these, and it can work, but not always, and sometimes extracting the maxillary 08 is the only way to resolve them.

If doing crown shortening I would take a parallel radiograph of the upper 08 crown initially to determine how far away the pulp is. You do not want to get too close to the pulp unless you fancy some rather fiddly endodontics! You generally only need to remove a very small amount of tooth to avoid ongoing trauma. I would normally use an unfilled resin to seal the exposed dentine tubules, though how important this is is probably debatable as long as you've not gone too close to the pulp. Obviously removing the enamel and exposing dentine will increase the risk of endodontic disease, and sometimes the cusp will still cause trauma and extraction is the only way forward.