Five most commonly misdiagnosed pathologies

Radiographs, metal hand explorers can supplement visual clues to dental health.

Radiographs can supplement the ability to evaluate the dentition below the gingival margin.
The basis for any accurate diagnosis is a thorough knowledge of the discipline of dental disease. The more one knows how to recognize the pathology and the prognosis for the condition, the more accurate the eventual diagnosis and treatment plan will be.

Arriving at the most definitive dental diagnosis requires a combination of four and often five avenues of approach. These are visual, tactile sense, dental radiography, dental probing, and often sedation or general anesthetic.

Two-thirds of the normal adult dentition is located beneath the gingival margin. An even larger percentage is subgingival prior to the exfoliation of the primary teeth. As a result, evaluation of the complete dental health of our patients often is extrapolated simply from the appearance of the dental crowns and to a much lesser degree, the mobility of the tooth.

A much more accurate evaluation will be obtained by augmenting with other diagnostic modalities. In dentistry, these are the periodontal probe, metal hand explorers and dental radiographs to supplement our ability to more accurately evaluate the dentition located below the gingival margin. It is highly recommended the use of these modalities become as routine and indispensable as the stethoscope and otoscope in the traditional veterinary health examination.

Not every patient must be sedated to evaluate the integrity of the oral cavity. But when probing subgingivally — which often requires accurate measurements within millimeters, dental radiography etc. — a high degree of patient compliance is required. Unfortunately, our veterinary patients aren't as tolerant of these diagnostic procedures as humans. Thus, required compliance can be acquired only by chemical means (anesthesia) in many instances.

As we will see, the inability to visualize the entire dentition and supporting structures leads to four of the five most common misdiagnoses we encounter in veterinary dentistry.

1. Inaccurately evaluating the periodontal state of the dentition. Simply relying on visualization of the dental crowns to evaluate periodontal health of the patient leads to the most common misdiagnosis in dentistry. This is especially true if one relies on calculus formation as a basis for degree of periodontitis.

Photo 1: Visually, the periodontal health of this canine tooth appears normal. Periodontal probing reveals the tooth has lost 12 mm of support bone.
When plaque lies relatively undisturbed in the sulcus surrounding the tooth, an inflammatory reaction occurs. The floor of the sulcus with its boney labial plate and supporting alveolar bone all around the tooth recedes and is eventually lost. The soft tissue of the gingiva usually recedes at a much slower rate, obliterating the boney labial plate destruction from view. As result, the degree of disease tends to be under appreciated. (See Photo 1.)

Because periodontal disease occurs subgingivally, the primary method to evaluate the degree of destruction accurately is through the use of the periodontal probe, and when indicated, dental radiology. By the use of these instruments, the sulcus depth and loss of support bone (attachment level) can be determined, charted and a specific plan of appropriate therapy initiated. (See related story)

2. Extracting teeth (proclaiming them hopeless prior to accurate evaluation). Old habits can die hard! The accepted treatment of choice for many years was simply to ignore the problem or extract.

Ask yourself: Would you like to save these teeth if they were yours? Humans primarily need our dentition for chewing food and cosmetics. Our patients, on the other hand, require teeth for mastication and as a substitute for their lack of hands. Consider how important your teeth would be if you had to pick everything up in your mouth instead of your hands! Our patients won't starve to death if they lose their teeth, but their quality of life certainly will suffer.

There are many teeth presented in practice every day that are truly hopeless and should be extracted (see related story). There are many more, however, that can be of service to the patient for years to come. Only by accurate dental diagnosis can we decide the proper therapy choice for each tooth.