Advanced Acquired Dental Disease in a 5 Year Old Rabbit Heather M. Lago DVM Class of 2009 April 8, 2009 Advisors: Drs. Marisa Bezjian & Ricardo DeMatos Meet Artemis 5 year old castrated male gray and white rabbit Image: www.aspcacommunity.ning.com History One month history: – Decreased appetite, decreased feces, progressive weight loss – CBC & chemistry panel no significant findings 6/16/08 – Chief Complaint: Continued inappetance & decreased feces – Physical examination: 20% weight loss (2.069 kg with BCS 4/9) – Oral examination: Moderate lingual point on right mandibular fourth cheek tooth filed – Plan: Computed Tomography Oral Examination Images: (above & bottom right) Brown, C. Intraoral examination in rabbits. Lab Animal 2008; 37 (9): 405-406.; (top right) Crossley DA. Oral biology and disorders of lagomorphs. Veterinary Clinics of North America: Exotic Animal Practice 2003; 6: 629-659. Problem List Decreased appetite Decreased feces/soft feces (intermittent) Progressive weight loss Teeth abnormalities Presumed oral pain Image: www.dentalcollectibles.com Differential Diagoses Acquired dental disease (with one or more of the following) – Cheek teeth malocclusion – Oral lesions (e.g. ulcerations) – Dental points/spurs/ridges – Tooth/gingival infection or abscess – Tooth root elongation Oral foreign body GI ulceration Gastrointestinal stasis or obstruction – Chronic foreign body Trichobezoar Metabolic disturbances – Renal failure – Hepatic lipidosis Oral neoplasia – Odontoma Congenital dental disease Computed Tomography Lytic changes around teeth roots Malaligned right arcades Absent crown and questionable tooth root fragment Cheek teeth root elongation For Artemis… Acquired dental disease – Cheek teeth malocclusion – Dental points/spurs/ridges – Tooth/gingival infection or abscess – Tooth root elongation Image: www.allanimation.com Acquired Dental Disease Normal Rabbit Dental Anatomy & Physiology 2 x 2/1 I 0/0C 3/2 P 3/3 M = 28 teeth Elodont dentition Peg tooth No canine teeth diastema Lateral active chewing jaw motion Specific diet required Images: (top right) Crossley DA. Oral biology and disorders of lagomorphs. Veterinary Clinics of North America: Exotic Animal Practice 2003; 6: 629-659.; (bottom right) Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits. Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. Etiology of Dental Disease Diet & Nutrition – Hay Fiber – Attrition Calcium – Maximal mineralization of teeth & skull bones Images: (top right) www.drsfostersmith.com ; (bottom right) Harcourt-Brown FM. Calcium deficiency, diet and dental disease in pet rabbits. The Veterinary Record 1996; 139: 567-571. Pathophysiology of Dental Disease *Malocclusion of incisors & cheek teeth Enamel spikes & ridges Crown & root elongation ELODONT DENTITION Mucosal trauma & pain Reduced food intake, ptyalism, & reluctance to chew Images: Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits. Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. Clinical Signs Oral pain Inability to close mouth Inappetance and dysphagia Weight loss and emaciation Changes in fecal size, quantity or appearance Ptyalism (“slobbers”) Dermatitis Epiphora & dacryocystitis Exophthalmos Facial masses or swellings Purulent nasal discharge Image: Harcourt-Brown FM. Diagnosis, treatment and prognosis of dental disease in pet rabbits. In Practice 1997; 19: 407-421. Diagnostics History (diet and clinical signs) Physical exam Oral exam Bloodwork Radiographs Other imaging – Endoscopy – CT scan Image: www.freeclipartnow.com Early Acquired Dental Disease Root and crown elongation Abnormal occlusal contact Crown deformities – Sharp enamel points/ridges Horizontal ridges (incisors) Images: Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits. Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. Advanced Acquired Dental Disease Cessation of individual tooth growth – Regular tooth trimming may no longer be necessary Dysplastic crowns – Disintegrated – Break off Images: (top right) Capello V. Clinical Technique: Treatment of Periapical Infections in Pet Rabbits and Rodents.Journal of Exotic Pet Medicine 2008; 17 (2): 124-131.; (bottom right) Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits.Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. End-Stage Acquired Dental Disease Most teeth are no longer growing Most crowns disintegrate or break off just below gumline – Gums heal and roots resorb Ankylosis of remnants of teeth & adjacent bone Images: Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits. Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. Treatment & Prognosis Treatment: management, NOT cure – Restoration of normal tooth length & occlusal plane as near normal as possible – Extraction of diseased teeth – Medical treatment of pain & infection Pain medication: Meloxicam Antibiotics: procaine penicillin G, enrofloxacin Probiotic supplement (e.g. Probios) – Medical and/or surgical treatment of periapical abscesses – Address weight loss and nutrition Critical Care Return to normal diet … maybe Fair to poor overall prognosis Back to Artemis Advanced Acquired Dental Disease Clinical Signs – PROGRESSIVE ! – Decreased appetite – Presumed oral pain – Ventral mandibular swelling – Weight loss – Decreased feces/soft feces (intermittent) – Many teeth abnormalities Image: www.dentalartgallery.com More History 11/20/08 – Presentation: Inappetance – Physical examination: 2.03 kg BW with BCS 4/9 (2.069 kg on 6/16) – Oral Examination under sedation: Shortened left mandibular arcade Left mandibular cheek tooth was cracked Prominent swelling, left side of ventral mandible – Plan: Repeat CT & Surgery Repeat CT Blunted and irregular roots with lysis of the adjacent alveolar bone Left mandibular second cheek tooth – Irregular crown with faint, mottled appearance Occlusal margins of cheek teeth are sharp and pointed R CT comparison R June 2008 November 2008 Exploratory Surgery The Future for Artemis Visit to the Exotics Service – 12/5/08 Eating better & normal feces Continued weight loss: – 1.98 kg with BCS 4/9 – ~24 % overall weight loss Ventral mandible surgery site healed well Long-term: – Status quo Pain medication, antibiotics, Critical Care Remove individual teeth as needed – Remove all teeth in the left mandibular and/or maxillary dental arcades – Eventual end-stage acquired dental disease Image: www.freeclipartnow.com References Brown, C. Intraoral examination in rabbits. Lab Animal 2008; 37 (9): 405-406. Crossley DA. Oral biology and disorders of lagomorphs. Veterinary Clinics of North America: Exotic Animal Practice 2003; 6: 629-659. Capello V. Clinical Technique: Treatment of Periapical Infections in Pet Rabbits and Rodents. Journal of Exotic Pet Medicine 2008; 17 (2): 124-131. Capello V, Cauduro A. Clinical Technique: Application of Computed Tomography for Diagnosis of Dental Disease in the Rabbit, Guinea Pig, and Chinchilla. Journal of Exotic Pet Medicine 2008; 17 (2): 93-101. Harcourt-Brown FM. Calcium deficiency, diet and dental disease in pet rabbits. The Veterinary Record 1996; 139: 567-571. Harcourt-Brown FM. Diagnosis, treatment and prognosis of dental disease in pet rabbits. In Practice 1997; 19: 407-421. Harcourt-Brown FM. The Progressive Syndrome of Acquired Dental Disease in Rabbits. Journal of Exotic Pet Medicine 2007; 16 (3): 146-157. Legendre LFJ. Malocclusions in guinea pigs, chinchillas and rabbits. The Canadian Veterinary Journal 2002; 43: 385-390. Lennox AM. Diagnosis and Treatment of Dental Disease in Pet Rabbits. Journal of Exotic Pet Medicine 2008; 17 (2): 107-113. Reiter AM. Pathophysiology of Dental Disease in the Rabbit, Guinea Pig, and Chinchilla. Journal of Exotic Pet Medicine 2008; 17 (2): 70-77. Tyrrell KL, Citron DM, Jenkins JR, et al. Periodontal Bacteria in Rabbit Mandibular and Maxillary Abscesses. Journal of Clinical Microbiology 2002; 40: 1044-1047. Verstraete FJM. Advances in Diagnosis and Treatment of Small Exotic Mammal Dental Disease. Seminars in Avian and Exotic Pet Medicine 2003; 12 (1): 37-48. Thank You ! Dr. Marisa Bezjian Dr. Ricardo DeMatos Dr. Sean Freer Dr. Peter Scrivani DVM Class of 2009 My husband, Ray Image: beabijoubea.blogspot.com Questions ? Image: www.alexross.com