A 14 yr. old miniature poodle presented for an oral examination 2-1/2 months after a dental cleaning and surgical extractions. The dog had non-healing extraction sites with proliferative tissue present on the upper right arcade that had not been recognized previously. The referring veterinarian was concerned that dehiscence of the surgical site was directly related to the mandibular dentition repeatedly traumatizing the extraction sites. Two rounds of antibiotics had not produced improvement, and the patient continued to exhibit signs of oral pain.
What diagnostic steps are necessary to determine the cause of the non-healing extraction sites in this patient?
Differential diagnosis for this case include: retained root tips preventing complete healing, resistant bacterial infection with chronic osteomyelitis, chronic ulcerative plasmacytic stomatitis (CUPS), and neoplasia. So, an anesthetized oral examination, full mouth dental radiographs, and submission of a biopsy for histopathologic evaluation is absolutely essential. Submission of a sample to the microbiology lab for culture and sensitivity testing may also be performed, but there are many bacteria in the oral cavity, and the challenge is to determine if they are pathogenic.
The anesthetized oral examination revealed 25 of 42 missing teeth, severely inflamed and hyperplastic tissue present along the right maxilla, and the presence of a large oronasal fistula starting at #103 and extending distally to the previous extraction site of #108. Heavy calculus and severe gingivitis was present along all of the teeth. Digital dental radiographs revealed Stage 4 periodontal bone loss on #410, #103, and #104, Stage 2 periodontal bone loss on all of the other teeth, and a retained root tip of #408.
Since no retained root tips were identified, the abnormal tissue overlying the right maxilla was excised and samples submitted for histopathology. #103 and #104 were extracted, a mucosal flap was lifted along the right maxilla, and the defect closed with 4-0 Monocryl by suturing the mucosa directly to the palatal tissue. #410 and the retained root tip of #408 were extracted, and the remaining teeth were ultrasonically scaled, polished, & OraVet was applied.
The patient’s post-op photo is below after completing the biopsy and extractions.
|Histopathology revealed that a neoplastic high-grade sarcoma was present at the extraction sites, with the pathologist noting it was most likely an amelanotic melanoma. Radiographs of the chest and abdomen and lymph node aspirates are recommended at this point to help stage the disease process and look for metastasis. The client was given a guarded prognosis and the patient referred to an oncologist for a consultation on additional treatment modalities. Additional pain medication was also dispensed to maintain the patient’s comfort level.|
By: Katherine Queck, DVM, FAVD