Differential Diagnosis
Acute facial swelling in a location typical for a tooth root abscess should be considered an abscess until proven otherwise. Neoplasia extending into the retrobulbar area typically does not present as acute swelling.
Treatment
Medical (see also Medications)
Acute emergency treatment consists of pain management and antibiotics if necessary. Surgery is required for definitive treatment. Antibiotic therapy should be only short term (while the patient is awaiting surgery) to prevent predisposing to bacterial resistance.
Surgical
Surgical treatment options are extraction or root canal treatment. Canine teeth and maxillary 4th premolars are good candidates for root canal treatment. After extraction, the patient should not receive hard treats or toys and should avoid rough mouth play for 2 weeks.
No Tooth, No Problem...Really?
Nutritional Aspects
Due to possible discomfort while eating, soft foods should be fed until the tooth can be treated. After endodontic therapy, the patient can return to a normal diet. After extraction, the patient should receive only soft food for an additional 10 to 14 days to protect the surgery site and sutures.
Client Education
Clients should be educated about which items are safe for their pets to chew and which are likely to fracture a tooth when a dog bites it with enough force. Hard, flat items (eg, hooves, bones), including many that are sold as dental care products, are the most hazardous. Any item that cannot be bent, indented with a fingernail, or easily broken by hand may fracture a tooth.
Medications
Drugs
After extraction or root canal therapy, an antibiotic (eg, amoxicillin-clavulanate or clindamycin) should be prescribed for 7 to 10 days. Pain management should include both preemptive (eg, morphine, ketamine delivered via constant rate infusion) and postoperative (eg, tramadol, nonsteroidal antiinflammatory drug of choice, buprenorphine) strategies.
Contraindications
Preoperative aspirin may increase bleeding and should be avoided.
Precautions
Long-term or repeated antibiotic therapy without surgery may resolve swelling and clinical signs temporarily, but these signs will eventually return. Teeth that have been fractured and left untreated for months can become poor candidates for root canal treatment because of root resorption, making extraction the only treatment option.
Follow-Up
Patient Monitoring
• Root canal treatment: There is no immediate follow-up care. Normal diet and activity can resume immediately.
• Extraction: A recheck of the extraction site should show excellent healing after 2 weeks.
Prevention
Avoiding dental trauma and severe periodontitis will prevent endodontic disease and, subsequently, dental abscess. Oral/dental examinations by the owner during daily brushing, owner education, annual veterinary oral and dental examinations, and veterinarian awareness of the causes and signs of endodontic disease can all help prevent and detect problems.
Complications
Conditions that can complicate root canal treatment include chronic inflammation that has damaged the root tip, internal or external root resorption, mechanical obstructions impeding navigation and treatment of the canals, complex endodontic anatomy, immature teeth with very large root canals, geriatric teeth with extremely narrow root canals, and vertical root fractures.
Potential complications of root canal treatment include failure to resolve the infection, instrument failure, root perforation, and inoculation of the periodontal tissues with materials that are extruded past the root apex.
Conditions that can complicate extraction include root fractures, root ankylosis in geriatric patients, and compromised supportive tissues that are easily damaged.
Potential complications of extractions include retained, infected root tips and damage to adjacent structures (punctured globe, fractured mandible, damaged vasculature).
Course
With treatment, swelling usually resolves in 7 to 10 days.
At-Home Treatment
Administration of antibiotics and pain medications if the tooth was extracted are the only treatment required at home.
Future Follow-Up
Root Canal Treatment: A dental radiograph should be obtained 1 year after treatment to evaluate healing of the periapical bone. Additional radiographs every 2 to 3 years are recommended. Any return of previous clinical signs (eg, swelling, favoring the affected side during eating, increased calculus on that side) is an indication for a radiograph regardless of the time since the procedure.
Extraction: There should be no need for long-term follow-up if the procedure was performed atraumatically and all root fragments were removed.
In General
Relative Cost
• Diagnosis and extraction (including pain management and anesthesia-related fees) $$
• Diagnosis and root canal treatment (including pain management and anesthesia-related fees) $$$
• Follow-up radiographs (including anesthesia-related fees) after root canal $$
Prognosis
The prognosis after extraction is excellent. Prognosis after root canal treatment is also excellent in the absence of the complicating factors described earlier. Prognosis decreases by varying degrees depending on the presence of complicating factors.
Future Considerations
Root canal treatment continues to become more and more predictable with the use of modern materials and instruments. The field of endodontics is rapidly changing, making it a more requested treatment option to return diseased teeth to function and health. As more veterinary practices offer dental radiography, clients and patients are given the option of in-house diagnosis and treatment.
TX at a glance
•Amoxicillin-clavulanate or clindamycin if there is marked swelling or discomfort and surgery cannot be performed for a few days
•Surgical extraction (with curettage and flush, followed by primary closure) or root canal treatment
•Either procedure should include postoperative antibiotic therapy for 7 to 10 days.