Radiographic evaluation in clinical practice of the types and stage of incisor tooth resorption and hypercementosis in horses

Retrospective assessment of the use of extended-release cabergoline in the management of equine pituitary pars intermedia dysfunction

Introduction

Dopaminergic agonists are accepted as the most effective treatment for pituitary pars intermedia dysfunction. However, some horses are refractory to daily oral pergolide, the recommended registered treatment. Extended-release cabergoline (ERC) injection may offer an alternative. The objective of this retrospective case series was to describe clinical and endocrinological responses to ERC.

Methods

Medical records of horses treated with weekly intramuscular injections of ERC (5 mg/mL, BOVA Aus) at either 0.01 mg/kg (high dose, HD) (n = 10) or 0.005 mg/kg (low dose, LD) (n = 30) were reviewed. Short-term ACTH responses were assessed at 5-8 days using a Wilcoxon signed ranked test. Longer-term ACTH responses (30 to 365 days) were assessed using generalised estimating equations.

Results

Five to eight days after the first dose of LDERC, median adrenocorticotropic hormone (ACTH) concentration was lower (p = 0.001), changing from 153 pg/mL (IQR: 78, 331) to 57 pg/mL (IQR: 30, 102). With HDERC, median ACTH concentration was also 153 pg/mL (IQR: 96, 185) before and then 56 pg/mL (IQR: 29, 86) after 5-8 days of treatment (p = 0.047). Over 12 months of treatment, ACTH concentration ranged from 14 to >1,250 pg/mL (median: 51 pg/mL) in horses treated with LDERC and 20 to 472 pg/mL (median: 50 pg/mL) in horses treated with HDERC. Measurements remained above the seasonal reference range in 39.3 and 52.3% of horses treated with LDERC and HDERC, respectively. Clinical improvement was reported by owners in 78.3 and 100% of horses treated with LDERC and HDERC, respectively. Partial, self-limiting inappetence was reported in 30.0% of LDERC and 60% HDERC cases. Seven horses exhibited lethargy (5 LDERC, 2 HDERC). Insulin concentrations measured 30 days post-ERC treatment were no different from baseline.

Discussion

Clinical and endocrinological responses were consistent with results of previous reports of oral pergolide treatment. Weekly injection of ERC may be an effective alternative to pergolide; the 0.005 mg/kg dose appeared to be as effective, with less risk of inappetence, than the 0.01 mg/kg dose that has been reported previously.

Three-Dimensional Segmentation Assisted with Clustering Analysis for Surface and Volume Measurements of Equine Incisor in Multidetector Computed Tomography Data Sets

Dental diagnostic imaging has progressed towards the use of advanced technologies such as 3D image processing. Since multidetector computed tomography (CT) is widely available in equine clinics, CT-based anatomical 3D models, segmentations, and measurements have become clinically applicable. This study aimed to use a 3D segmentation of CT images and volumetric measurements to investigate differences in the surface area and volume of equine incisors. The 3D Slicer was used to segment single incisors of 50 horses' heads and to extract volumetric features. Axial vertical symmetry, but not horizontal, of the incisors was evidenced. The surface area and volume differed significantly between temporary and permanent incisors, allowing for easy eruption-related clustering of the CT-based 3D images with an accuracy of >0.75. The volumetric features differed partially between center, intermediate, and corner incisors, allowing for moderate location-related clustering with an accuracy of >0.69. The volumetric features of mandibular incisors' equine odontoclastic tooth resorption and hypercementosis (EOTRH) degrees were more than those for maxillary incisors; thus, the accuracy of EOTRH degree-related clustering was >0.72 for the mandibula and >0.33 for the maxilla. The CT-based 3D images of equine incisors can be successfully segmented using the routinely achieved multidetector CT data sets and the proposed data-processing approaches.

An application of the density standard and scaled-pixel-counting protocol to assess the radiodensity of equine incisor teeth affected by resorption and hypercementosis: preliminary advancement in dental radiography

BACKGROUND

Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) syndrome is a dental disease where the radiographic signs may be quantified using radiographic texture features. This study aimed to implement the scaled-pixel-counting protocol to quantify and compare the image structure of teeth and the density standard in order to improve the identification of the radiographic signs of tooth resorption and hypercementosis using the EOTRH syndrome model.

METHODS AND RESULTS

A detailed examination of the oral cavity was performed in 80 horses and maxillary incisor teeth were evaluated radiographically, including an assessment of the density standard. On each of the radiographs, pixel brightness (PB) was extracted for each of the ten steps of the density standard (S1-S10). Then, each evaluated incisor tooth was assigned to one of 0-3 EOTRH grade-related groups and annotated using region of interest (ROI). For each ROI, the number of pixels (NP) from each range was calculated. The linear relation between an original X-ray beam attenuation and PB was confirmed for the density standard. The NP values increased with the number of steps of the density standard as well as with EOTRH degrees. Similar accuracy of the EOTRH grade differentiation was noted for data pairs EOTRH 0-3 and EOTRH 0-1, allowing for the differentiation of both late and early radiographic signs of EOTRH.

CONCLUSION

The scaled-pixel-counting protocol based on the use of density standard has been successfully implemented for the differentiation of radiographic signs of EOTRH degrees.

Equine odontoclastic tooth resorption and hypercementosis (EOTRH): microspatial distribution of trace elements in hypercementosis-affected and unaffected hard dental tissues

Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) is a common, painful and poorly understood disease. Enamel, dentin and cementum accumulate both essential and toxic trace elements during mineralization. Characterization of the spatial accumulation pattern of trace elements may provide insight into the role that toxic elements play and inform biological processes affecting these hard dental tissues for future research. Laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) was used to map the distribution of multiple trace elements and heavy metals across equine healthy and diseased (hypercementosis-affected) hard dental tissues among four teeth extracted from horses with EOTRH. Results showed banding patterns of some trace elements (lead, strontium, barium), reflecting the temporal component of accumulation of trace elements during dentin mineralization. Essential elements zinc and magnesium did not show banding patterns. Comparison to the unaffected cementum and dentin adjacent to the hypercementosis region showed that there is an underlying incremental pattern in the uptake of some metals with spatial irregularities. This supports a possible metabolic change involved in hypercementosis lesion development. This represents the first use of LA-ICP-MS to study the microspatial distribution of trace elements in equine teeth, establishing a baseline for elemental distribution in normal and EOTRH impacted dental hard tissue.

Early incisor lesions and Equine Odontoclastic Tooth Resorption and Hypercementosis: Reliability of radiographic findings

BACKGROUND

In clinical practice, early diagnosis of Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) and other resorptive incisor diseases is difficult to achieve. The radiographic appearance of subtle pathological changes has not been described in detail and might be confused with age-related changes.

OBJECTIVES

The study was performed to define typical radiographic signs of early incisor lesions and to evaluate the reliability of the radiographic findings.

STUDY DESIGN

Descriptive and comparative study using post mortem clinical, radiographic, macroscopic and µCT examination.

METHODS

The incisor region of 20 cadaveric horse heads, divided into three different age groups, was examined visually and by palpation. Intraoral radiographs were taken. After extraction, each incisor was macroscopically evaluated. Micro-computed tomography (µCT) scans were obtained. These scans were processed with Scry (v6.0, Kuchel & Sautter GbR) to obtain surface meshes which then were transferred to Meshlab (ISTI-CNR, version 2016.12). Attached tissues were virtually removed and surface curvature was computed to visualise and evaluate the quantity of unevenness (roughness) of the teeth's surface. Scoring systems for each diagnostic modality were developed. Scores were compared to describe and evaluate the radiographic appearance of early incisor lesions.

RESULTS

The prevalence and severity of incisor lesions increased with age. Early, subtle lesions develop on the palatal/lingual side of incisors. While radiographically detected lesions were confirmed macroscopically and on the µCT scans, numerous teeth which were radiographically classified as healthy displayed lesions by macroscopic inspection (13.7%) and µCT analysis (58.1%).

MAIN LIMITATIONS

Cadavers were studied and dental history was unknown.

CONCLUSIONS

The detection of early and subtle incisor lesions indicating first signs of EOTRH on dorsoventral intraoral radiographs is limited due to the typical localisation of the lesions on the palatal/lingual side of the incisors.

Application of Two-Dimensional Entropy Measures to Detect the Radiographic Signs of Tooth Resorption and Hypercementosis in an Equine Model

Dental disorders are a serious health problem in equine medicine, their early recognition benefits the long-term general health of the horse. Most of the initial signs of Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) syndrome concern the alveolar aspect of the teeth, thus, the need for early recognition radiographic imaging. This study is aimed to evaluate the applicability of entropy measures to quantify the radiological signs of tooth resorption and hypercementosis as well as to enhance radiographic image quality in order to facilitate the identification of the signs of EOTRH syndrome. A detailed examination of the oral cavity was performed in eighty horses. Each evaluated incisor tooth was assigned to one of four grade-related EOTRH groups (0-3). Radiographs of the incisor teeth were taken and digitally processed. For each radiograph, two-dimensional sample (SampEn2D), fuzzy (FuzzEn2D), permutation (PermEn2D), dispersion (DispEn2D), and distribution (DistEn2D) entropies were measured after image filtering was performed using Normalize, Median, and LaplacianSharpening filters. Moreover, the similarities between entropy measures and selected Gray-Level Co-occurrence Matrix (GLCM) texture features were investigated. Among the 15 returned measures, DistEn2D was EOTRH grade-related. Moreover, DistEn2D extracted after Normalize filtering was the most informative. The EOTRH grade-related similarity between DistEn2D and Difference Entropy (GLCM) confirms the higher irregularity and complexity of incisor teeth radiographs in advanced EOTRH syndrome, demonstrating the greatest sensitivity (0.50) and specificity (0.95) of EOTRH 3 group detection. An application of DistEn2D to Normalize filtered incisor teeth radiographs enables the identification of the radiological signs of advanced EOTRH with higher accuracy than the previously used entropy-related GLCM texture features.

Equine Odontoclastic Tooth Resorption and Hypercementosis

Equine odontoclastic tooth resorption and hypercementosis (EOTRH) is a recently described painful and progressive condition of unknown etiology that occurs in middle-aged and geriatric equines. It predominantly affects the permanent incisor and canine teeth and, less commonly, the premolar and molar dentition. EOTRH was first reported in peer-reviewed literature in 2008, with subsequent publications of case reports, histological studies and retrospective case series. There have been few significant research developments related to this disease. The existing studies have primarily involved single case studies or small sample sizes, without control groups. This review aimed to report current information about EOTRH in terms of clinical, histopathological, diagnostic, radiological, and therapeutic aspects, by searching the available peer-reviewed scientific literature.

Diagnostic value of full-mouth radiography in horses

In this observational study, oral examinations and full-mouth dental radiographs were performed on 248 horses presented for routine oral health care. The findings were assessed to determine how often disease was diagnosed by radiographs without having related findings on oral examination. In 50 horses (20%), there were radiographic signs of disease that would not have been predicted based upon the oral examination. 113 horses (46%) had oral examination findings that would have prompted dental radiography, according to the criteria of the study. Of these 113 horses, 24 (21%) had radiographic signs of disease that would have been missed if only targeted radiographs had been taken, rather than a full-mouth survey.

Equine Incisor Lesions: Histologic Confirmation of Radiographic, Macroscopic, and Micro-Computed Tomographic Findings

Simple Summary

Incisor diseases are a common problem in equine medicine. However, Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) and other lesions are often only diagnosed in advanced stages. In this study, the incisors of 20 horses were examined. The findings of X-rays, macroscopical inspection, and micro-computed tomography (µCT) were compared. Five categories from healthy to severely affected teeth were formed and selected teeth from each category were additionally examined by means of histology. Odontoclastic resorption of dental hard substances, infiltration of inflammatory cells, areas of irregular dental cementum, and formation of granulation tissue were observed. Resorptive lesions previously detected by µCT were confirmed by microscopical imaging, however, not all resorptive lesions were regarded as a pathological condition like EOTRH. Detailed microscopical inspection revealed the presence of so-called surface resorptions which represent repaired resorptive lesions without any pathological consequence for the horse. Nevertheless, some incisors which appeared healthy on the X-rays featured histological findings related to EOTRH. Therefore, the detection of early incisor lesions in equine medicine remains challenging.

Abstract

Equine Odontoclastic Tooth Resorption and Hypercementosis (EOTRH) and other incisor lesions are often diagnosed only in advanced stages. The incisors of 20 horses were examined radiographically, macroscopically, and via micro-computed tomography (µCT) to discriminate EORTH-affected teeth. Five categories from healthy to severely affected teeth were formed and teeth from each category were examined histologically to evaluate the opportunity of earlier radiographic diagnosis. Histologically, odontoclastic resorptive lesions, leukocytic infiltrations, and areas of irregular cementum and granulation tissue were observed. The extent and severity of histological findings were correlated to the µCT data. Micro-CT imaging was suitable to detect subtle irregularities in the dental substances which were referred to as resorptive lesions. Although histological examinations confirmed the presence of resorptive lesions, not all of them were classified as pathological conditions. Instead, repaired surface lesions were documented which were regarded as a physiological condition. Nevertheless, incisors which were radiographically regarded as healthy can also feature histological signs of EOTRH. Therefore, due to the possibility of misinterpreting radiographic findings combined with superimpositions on intraoral radiographs, the detection of early resorptive lesions remains challenging.

Equine odontoclastic tooth resorption and hypercementosis: investigating individual incisor disease patterns using radiological classification

BACKGROUND

Equine odontoclastic tooth resorption and hypercementosis (EOTRH) is a destructive, painful, and underdiagnosed dental disorder. Radiography is necessary to fully assess the disease as early stages occur on clinically normal teeth.

OBJECTIVES

To investigate the distribution pattern of appearance of EOTRH within the incisor arcade. In particular, we aimed to determine the influence of tooth position and age on the severity and its frequency of the individual tooth.

STUDY DESIGN

Retrospective cross-sectional radiographic case study.

METHODS

Digital radiographs of 142 horses (10 years and older) presented for routine dental examination at our Equine Hospital were obtained and evaluated for changes related to EORTH. Radiological findings were classified in terms of EOTRH severity and each tooth was evaluated individually (tooth stage).

RESULTS

The tooth stages of EOTRH showed a bilateral symmetrical distribution pattern over the entire incisor arcade. There was a significant positive correlation between age and tooth stages (P<0.001, rho=0.48, 95% CI 0.43-0.51), and the frequency of higher tooth stages increased from central incisors to middle and corner incisors.

MAIN LIMITATIONS

Individual head anatomy in some male horses lead to superimposition of the lower jaw corner incisors and canine teeth. The radiographic technique proved difficult in smaller and uncooperative horses. Differentiating between mild pathological signs of EOTRH and age-related radiological changes was not possible in all cases.

CONCLUSION

These results reconfirm an age correlated progression of EOTRH. EOTRH affects the incisor arcade in a bilaterally symmetrical pattern with the corner incisors being the most severely affected.

Selection of Filtering and Image Texture Analysis in the Radiographic Images Processing of Horses' Incisor Teeth Affected by the EOTRH Syndrome

Equine odontoclastic tooth resorption and hypercementosis (EOTRH) is one of the horses’ dental diseases, mainly affecting the incisor teeth. An increase in the incidence of aged horses and a painful progressive course of the disease create the need for improved early diagnosis. Besides clinical findings, EOTRH recognition is based on the typical radiographic findings, including levels of dental resorption and hypercementosis. This study aimed to introduce digital processing methods to equine dental radiographic images and identify texture features changing with disease progression. The radiographs of maxillary incisor teeth from 80 horses were obtained. Each incisor was annotated by separate masks and clinically classified as 0, 1, 2, or 3 EOTRH degrees. Images were filtered by Mean, Median, Normalize, Bilateral, Binomial, CurvatureFlow, LaplacianSharpening, DiscreteGaussian, and SmoothingRecursiveGaussian filters independently, and 93 features of image texture were extracted using First Order Statistics (FOS), Gray Level Co-occurrence Matrix (GLCM), Neighbouring Gray Tone Difference Matrix (NGTDM), Gray Level Dependence Matrix (GLDM), Gray Level Run Length Matrix (GLRLM), and Gray Level Size Zone Matrix (GLSZM) approaches. The most informative processing was selected. GLCM and GLRLM return the most favorable features for the quantitative evaluation of radiographic signs of the EOTRH syndrome, which may be supported by filtering by filters improving the edge delimitation.

EOTRH Syndrome in Polish Half-Bred Horses - Two Clinical Cases

The aim of this paper is to thoroughly describe the etiology, diagnostic processes and recommended treatment of equine odontoclastic tooth resorption and hypercementosis (EOTRH). It is a relatively recently described disease. Most recent reports show that it is a common problem involving older equine patients. The most common and significant symptom of EOTRH is oral pain. The main clinical signs include periodontitis and gingivitis with a gingival recession, alveolar bone protrusion, periodontic fistulas and soreness of the incisors. When establishing the final diagnosis, it is necessary to compare the results of the clinical and radiological examination, because in the early stage, the disease may not show any symptoms. Authors used two clinical cases of Polish Half-Bred horses to present some aspects of diagnostic and surgical techniques. The knowledge presented in the paper may be valuable for equine practitioners working in the field to achieve more beneficial outcomes and provide a higher level of welfare for their equine patients. Nevertheless, further research and observations are necessary, since the etiology of the disease remains unclear.

Update on Equine Odontoclastic Tooth Resorption and Hypercementosis

Equine odontoclastic tooth resorption and hypercementosis (EOTRH) is a progressive, painful disease, affecting incisors, canines, and cheek teeth. Examination findings include gingival inflammation, gingival recession and/or hyperplasia, subgingival swelling, bulbous enlargement of teeth, associated periodontal disease, pathologic tooth fracture, and/or tooth mobility and loss. Current hypotheses include biomechanical stresses and secondary bacterial involvement. Early recognition allows case management, but it is a progressive disease. Owner education is crucial; horses with complete or multiple extractions have a favorable prognosis. Human oral and dental health may be affected by bisphosophonate use; long-term effects of these drugs are currently unknown in horses.

Dental Radiography and Radiographic Signs of Equine Dental Disease

Radiography is an important imaging modality and is available to most equine veterinarians providing primary care. Diagnostic radiographic imaging of the equine skull and dentition requires careful positioning and technique. This article is aimed at providing the veterinarian with instructions and guidelines for obtaining diagnostic skull and dental radiographs and a discussion of the radiographic signs of dental disease with case-based examples. The limitations of radiography are discussed with regard to determining the need for adjunct diagnostic techniques and more advanced imaging techniques, such as computed tomography.

World Small Animal Veterinary Association Global Dental Guidelines

Dental, oral, and maxillofacial diseases are some of the most common problems in small animal veterinary practice. These conditions create significant pain as well as localized and potentially systemic infection. As such, the World Small Animal Veterinary Association (WSAVA) believes that un- and under treated oral and dental diseases pose a significant animal welfare concern. Dentistry is an area of veterinary medicine which is still widely ignored and is subject to many myths and misconceptions. Effective teaching of veterinary dentistry in the veterinary school is the key to progression in this field of veterinary medicine, and to the improvement of welfare for all our patients globally. These guidelines were developed to provide veterinarians with the information required to understand best practices for dental therapy and create realistic minimum standards of care. Using the three-tiered continuing education system of WSAVA, the guidelines make global equipment and therapeutic recommendations and highlight the anaesthetic and welfare requirements for small animal patients. This document contains information on common oral and dental pathologies, diagnostic procedures (an easily implementable and repeatable scoring system for dental health, dental radiography and radiology) and treatments (periodontal therapy, extractions). Further, there are sections on anaesthesia and pain management for dental procedures, home dental care, nutritional information, and recommendations on the role of the universities in improving veterinary dentistry. A discussion of the deleterious effects of anaesthesia free dentistry (AFD) is included, as this procedure is ineffective at best and damaging at worst. Throughout the document the negative effects of undiagnosed and/or treated dental disease on the health and well-being of our patients, and how this equates to an animal welfare issue, is discussed.

Computed Tomography (CT)-Assisted 3D Cephalometry in Horses: Interincisal Angulation of Clinical Crowns

The angle encompassed between opposing incisors in horses is assumed to decline with age. Previous studies merely consider the overall profile view of clinical crowns presuming a generalized angle, neglecting potential tooth position-dependent differences. Cephalometric measurements from 3D computed tomographic thick-slab reconstructions of single incisors within a global reference frame were used to determine clinical crown interincisal angulation (IIA) of 48 horses. Based on predefined dentoalveolar landmarks, IIA was defined as the angle enclosed by the respective labial axis of the clinical crown (LACC). A measurement repeatability analysis was conducted including a comparison of third incisor teeth IIA with data obtained by cephalometric implementation of previously described landmarks for third incisor teeth (lingual/palatal border). The age-related angle course and differences between tooth positions were investigated considering LACCs of permanent incisors. Determining IIA by LACCs exhibited a high level of reproducibility applying for all tooth positions (mean coefficient of variation = 0.65 %; mean SD ± 0.89°). The comparison method for third incisor teeth revealed two times higher mean dispersion of repeated measurements, P = 0.017. A non-linear model slightly increased predictability of angular changes over time as against linearity assumption. The angle decline was more distinctive in younger horses and appears to approach a final value in older ones. Third incisor teeth exhibited significantly higher angle decline compared to first and second incisor teeth, P < 0.0001. According to the results, age determination of horses using clinical crown IIA is not recommended. Rather, 3D cephalometry may provide a promising tool to determine interdental and dentofacial angles of distinct tooth positions in health and disease.

History, clinical findings and outcome of horses with radiographical signs of equine odontoclastic tooth resorption and hypercementosis

The progression of equine odontoclastic tooth resorption and hypercementosis (EOTRH) has not been completely evaluated, and currently, the only effective treatment is extraction of severely affected teeth. We aim to describe how the disease relates to the history and clinical findings and to report on the outcome in individual horses. This case series comprises data collected from 20 horses (age 14–29 years old) with radiographic findings of EOTRH in their incisor and/or canine teeth. Most horses affected with EOTRH in this study were admitted for dental problems, but some for other complaints such as colic. Of the 288 teeth evaluated radiographically, 224 teeth were abnormal. Radiographic findings were most frequently located in the apical aspect and reserve crown of the teeth, and lesions were also commonly found in clinically normal teeth. Histopathology of extracted teeth showed inflammation in the periodontal ligament and revealed that resorption often extended to the dentine. Some owners were unwilling to allow extraction of their horses’ severely affected teeth, even though this treatment has been shown to increase the wellbeing of the horse. As EORTH is a life-long condition, the progression of the disease has to be continuously monitored and the treatments adjusted accordingly.