Visiting Vet: Looking a sick dog in the mouth

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at: drjasny@comcast.net.

The term epulis comes from the Greek word epoulis, meaning gumboil. The word could be used to describe any mass on the gums, but in veterinary medicine, we use it to refer to a specific group of benign tumors that arise from the cells that form the periodontal ligaments.

There are a number of things I find confounding about these oral growths. The first is that the plural of epulis is epulides (pronounced e-pew-li-deez.) That always gets me tongue-tied. The second confounding thing is the fancy nomenclature used to identify the various types of epulides — and they keep changing the terminology.

There are basically three classifications of epulides. Bear with me now. We are about to encounter a whole lot of multi-syllabic words.

A fibromatous epulis (seven syllables) is a smooth pink growth on the gum, often near the upper incisor, canine, or premolar teeth. It may dangle from a stalk, or just be a thick flap protruding down around a tooth. The surface usually looks pretty much like the surrounding gum tissue, and is not irritated or ulcerated.

Next we have peripheral odontogenic fibromas (12 syllables), formerly know as ossifying epulides. These look similar but arise from bone-related cells called osteoblasts and feel more solid.

The third type is acanthomatous ameloblastoma (11 syllables), previously called acanthomatous epulis. These often look very different, having an irregular cauliflower-like appearance, and occur most frequently around the front incisors and canine teeth, on either the upper or lower jaw. Although classified as benign, these epulides are locally aggressive, invading the adjacent bone, and can be quite deforming. All these big words help veterinarians think about the source of the growths and how they should be treated.

Checking the teeth

So let’s take our dog, Gummy Bear. He’s come in for his annual physical exam. Let’s say he’s middle-aged. Most epulides occur in older dogs, with the average age being seven years. Maybe he’s a boxer, or a pug, since short-faced dogs are very prone to epulides, though they can occur in any breed. As part of our routine exam, we check Gummy Bear’s teeth. Maybe his gums are a little swollen or inflamed. Some dogs get a condition called gingival hyperplasia which is simply an exuberant growth of gum tissue that occurs in response to inflamation, trauma (such as a tooth chronically rubbing on the gum), infection, or certain medications.

Maybe he has a lot of dental tartar. We might recommend a dental cleaning, or home care like regular tooth-brushing with a doggy-friendly toothpaste. (Remember dogs don’t “rinse and spit” so dental care products must be safe for them to swallow.) Or perhaps his mouth looks fine except we notice a growth on his gums that looks like an epulis

What do I recommend? There are other tumors besides epulides that may occur in the mouth that can be very serious, such as squamous cell carcinoma, malignant melanoma, or fibrosarcoma.

If your veterinarian is concerned that Gummy Bear’s mass might be a malignant cancer, not a benign epulis, then you will likely be encouraged to authorize a biopsy. Sometimes we can nip off a small piece of tissue  right there in the exam room, but depending on the location, size, and shape of the mass, as well as the temperament of the patient, general anesthesia may be necessary to get a biopsy. In that case, your veterinarian may recommend just going ahead with definitive treatment. For fibromatous epulides and peripheral odontogenic fibromas, recommended treatment involves excising the mass, and often extracting the involved tooth and scraping out the socket (technically called curettage of the alveolus) to try to be sure all abnormal tissue is removed. Acanthomatous ameloblastomas, which invade the bone,  require much more aggressive surgery, actually removing part of the affected upper or lower  jaw bone. It is best to have this done by a board-certified veterinary surgeon. They may advise X-rays of the head to try to determine how invasive the epulis is, and/or chest films to rule out metastasis, though nowadays, more advanced imaging such as MRI or CT scans  can give much more accurate information.

Wait and see?

Most of the time, however, you probably won’t even know Gummy Bear has an epulis, unless it is unusually large or in an area affecting his ability to eat, in which case signs may include drooling, bad breath, and/or facial deformity. In those situations, surgical intervention is clearly advisable. But if a growth looks like a classic fibromatous epulis, is relatively small, and isn’t bothering Gummy or causing clinical symptoms, in my opinion, it is reasonable to take a conservative “wait and see” approach. If I have a dog anesthetized anyway for a dental cleaning, I will sometimes “debulk” an epulis, trimming it back to what looks like the normal gum margins (so it is less likely to be traumatized when the animal chews), but not extracting an otherwise healthy tooth and scraping the socket. And if Gummy doesn’t need anesthesia for other reasons, I will frequently just leave epulides alone, just having owners keep an eye on them. Veterinary oncologists and dentists reading this are now jumping up and down in their seats, yelling at the newspaper in protest, so I must qualify my statement.

I have heard it said by oncologists that “let’s wait and see” are the most dangerous words in the English language. Of course early intervention is often the smart choice, especially with malignant cancer or locally invasive and aggressive tumors. It’s also true that we cannot definitively predict how any growth will progress, so the conventional wisdom of many veterinarians is that all epulides should be removed. But I have seen numerous senior dogs with slow-growing benign epulides that were not removed and that had no significant effect on either their well-being or their longevity. So if Gummy Bear grows a gummy mass, discuss it with your veterinarian. What to do depends a lot on your personal philosophy, your finances, your veterinarian, and Gummy Bear’s exact circumstances.