Endodontic disease has long been known as a common cause of a non-healing facial wound.1 The most common manifestation of this is the slab fracture of the maxillary fourth premolar tooth, which often results in pulp exposure, endodontic infection and a draining cutaneous tract below the medial canthus of the ipsilateral eye.
This column compares two persistent cases I’ve seen recently that presented with similar problems but different etiologies.
Jasper the Westie
Case No. 1: Jasper, a 5-year-old male neutered West Highland white terrier, was presented to me with a three-month history of a non-healing wound beneath his left eye. The wound resolved when the primary care veterinarian placed Jasper on antibiotics, but recurred once antibiotics were discontinued.
One year earlier, Jasper had received a dental cleaning and extraction of the left maxillary first molar due to severe periodontal disease.
Jasper was presented to me for evaluation of any other dental issues that might be causing the non-healing sinus tract and scabbing beneath the left ventral eyelid. On conscious examination, Jasper was reluctant to allow for a good evaluation of the left maxillary quadrant, but I determined that the left maxillary fourth premolar (tooth 208) was present and did not appear to have any crown fractures.
The left maxillary first molar (tooth 209) was missing and the site of the previous extraction appeared to be fully healed. The crown of tooth 208 was intact but after the patient was anesthetized and calculus was removed from the tooth, its crown appeared to be a discolored tan/light brown color.
We placed Jasper under general anesthesia to obtain dental radiographs. They confirmed that tooth 209 was completely extracted previously with no evidence of root remnants that might be contributing to the draining facial wound. The radiograph of tooth 208 showed periapical lucency and loss of normal apical periodontal ligament space around the distal root, suggestive of abscess or granuloma. Tooth 208 was surgically extracted. The facial wound resolved within one month of the extraction of.
Odie the Cairn
Case No. 2: Odie, a 10-year-old male neutered cairn terrier presented with severe crusting beneath the left eye with evidence of a sanguinopurulent discharge beneath a large scab that encompassed the entire ventral eyelid.
Before coming to me, Odie had evidence of a slab fracture with pulp exposure of the left maxillary fourth premolar (tooth 208). This tooth was extracted by Odie’s primary care veterinarian and, shortly after the extraction, it appeared the facial wound was on the mend.
However, months later, the facial wound recurred and though antibiotics helped somewhat, the facial wound would not resolve completely.
Conscious oral examination was difficult due to severe patient sensitivity when evaluating the left maxilla. Odie was anesthetized and dental radiographs showed no evidence of retained root tips from the previous extraction of tooth 208, and no evidence of endodontic disease of teeth adjacent to the previously extracted tooth.
However, on close inspection of the previous extraction site, a draining sinus tract was evident intraorally in the area of missing tooth 208 that communicated with the facial wound on probing.
After removing the unexpected foreign body and closing the intraoral draining tract with a mucoperiosteal flap, the facial wound healed within a few weeks postoperatively.
Jasper’s case is a good reminder that a tooth does not need to be fractured or worn to become nonvital and infected, and tooth infection may manifest as facial swelling but it may sometimes result in a non-healing facial wound.
More than 92 percent of intrinsically discolored teeth are either partially or completely necrotic on exploratory pulpotomy.2 Odie’s case is a rare manifestation.
In most cases, lack of resolution of a facial draining tract after extraction of a pulp-exposed tooth is due to incomplete removal of the tooth, or due to an adjacent tooth that is also nonvital. In this case, a persistent oral communication into the subcutaneous space allowed for a foreign body to act as a chronic nidus for infection.
Dr. Lewis, FAVD, Dipl. AVDC, practices veterinary dentistry and oral surgery at NorthStar Veterinary Emergency Trauma & Specialty Center in Robbinsville, N.J.
1. Lewis JR (Cote, E, ed.). Tooth fractures. Clinical Veterinary Advisor, 2nd ed. Philadelphia: Mosby Elsevier. 2011; 1102-1103.
2. Hale, FA. Localized intrinsic staining of teeth due to pulpitis and pulp necrosis in dogs. J Vet Dent 2001; 18(1): 14-20.