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INTRODUCTION Dental pathology has been reported as
the most common
cause of secondary sinusitis in horses in several studies (Dixon et al., 2011 ; Tremaine & Dixon, 2001a ). Pathology within the four caudal-most maxillary cheek teeth (Triadan system 108-11 and 208-11) can result in an inflammation of the sinus mucosa due to the close relationship between the tooth roots and the adja- cent sinus mucosa (Easley & Freeman, 2013 ; Liuti et al., 2017 ; Tremaine et al., 1999 ). Consequently, the spreading of bacteria in cases of apical infection may lead to a chronic bacterial inocula- tion of the paranasal sinuses and the resultant excessive mucus and purulent exudate subsequently drains down the ipsilateral nostril (O ' Leary & Dixon, 2011 ). Hence, nasal discharge has been shown to be present in 98–100% of cases with dental sinusitis (Dixon et al., 2011 ; Tremaine & Dixon, 2001a ). Upon diagnosis of dental sinusitis in a horse, the subsequent extraction of the dis- eased tooth/teeth constitutes a fundamental component of the treatment regimen aimed at eradicating the underlying aetiology of disease. Despite the use of less invasive techniques of dental extraction, administration of broad-spectrum antibiotics (AB) and the use of concurrent sinus surgery for debridement and lavage are still customary practice whenever horses are treated for den- tal sinusitis (Dixon et al., 2005 , 2012a , 2021 ; Hart & Sullins, 2011 ; Perkins et al., 2009 ). The use of broad-spectrum AB may be ques- tionable practice in the light of the increased presence of drug-re- sistant pathogens in both veterinary and human medicine. The World Health Organization (WHO) has, moreover, declared antibi- otic resistance to be a global threat to human health (World Health Organization, 2012 ). In addition to the increased risk of antibiotic resistance development, the administration of AB in horses may also give rise to various adverse effects including but not limited to diarrhoea, muscle soreness, colic and anaphylactic reactions, calling for further action to reduce the utilisation of AB in equine clinics (Haggett & Wilson, 2008 ). Interestingly, the various diver- gent extraction and surgical techniques, of which several are used simultaneously, in previous studies make it difficult to assess the effectiveness of each procedure (Caramello et al., 2020 ; Dixon et al., 2000 , 2005 , 2012a ; Langeneckert et al., 2015 ; Prichard et al., 1992 ; Tremaine & Dixon, 2001b ). Trephination and bone flap surgery are not only traumatic but often require hospitalisa- tion for several days for repeated lavage of the sinuses leading to additional trauma for the horse and costs for the owner (Dixon et al., 2012a ; Hart & Sullins, 2011 ; Perkins et al., 2009 ; Quinn et al., 2005 ). For the above-mentioned reasons, it is thus imper- ative to investigate the minimally required treatment for a horse with dental sinusitis to be fully cured. This may eventually result in reduced use of AB and potentially also less trauma to the horse. Therefore, the aim of this study is to assess the effect of
peri-operative AB tooth extraction on the probability of achiev- ing a complete recovery in horses diagnosed with dental sinusitis subjected to extraction of the diseased tooth. Our null hypothe- sis being that there is no difference in the probability for success
LYDIKSEN ET AL.
(remission of clinical signs and no need for further treatment) whether AB are used in the treatment of dental sinusitis or not. In addition, we wish to evaluate the success of dental cheek tooth extraction as a sole treatment of dental sinusitis without the use of AB and sinus surgery.
MATERIALS AND METHODS Data and data collection
The study is a retrospective cohort study reviewing and analys- ing data from clinical records of horses presenting with nasal dis- charge at Hestetandklinikken (HTK), a specialised equine dental referral clinic, between September 2016 and May 2022. Horses eligible for inclusion presented with nasal discharge and under- went ≥1 dental extraction(s) (standing oral extraction or MTE) as the sole treatment or as part of the treatment regimen in horses with a confirmed diagnosis of dental sinusitis. Sinusitis was di- agnosed when a horse presented with unilateral/bilateral nasal discharge and dental sinusitis diagnosed when the horse concur- rently had one or more of the following gross dental abnormalities in one of the four maxillary caudal-most cheek teeth; pulpar expo- sure, advanced caries, fractures, and diastemas and/or if a tenta- tive diagnosis of dental sinusitis was made based on radiographic, endoscopic and/or computed tomography (CT) findings. Lateral oblique radiographs were obtained of all horses and examined by experienced equine dental practitioners from HTK, for any evi- dence of apical infection (Barakzai, 2011 ; Townsend et al., 2011 ). Latero-lateral projections of the sinuses were only obtained in se- lected cases for detection of fluid lines or presence of increased radiopacity within the sinuses. Horses were excluded from a diag- nosis of dental sinusitis based on one or more of the following rea- sons: (1) If no other primary cause for nasal discharge was found (primary sinusitis), (2) if a cause other than dental pathology was identified as the cause of nasal discharge (sinus cyst, progressive ethmoidal haematoma or other), (3) if the sinusitis developed sub- sequent to a dental extraction (iatrogenic sinusitis). The data recorded from each horse included case history; age
at admission; breed and sex of the horse; duration of clinical signs and treatment prior to admission; clinical signs and dental pathol- ogy associated with sinusitis; Triadan number of diseased tooth/ teeth; surgeon; extraction method and postoperative treatment. Duration of clinical signs was characterised as either subacute dis- ease (nasal discharge of <2 months ' duration) or chronic disease (nasal discharge of >2 months ' duration). To obtain missing data (data that could not be retrieved from the record) and additional information regarding the follow-up period, a questionnaire was emailed to horse owners followed by a reminder 10 and 20 days later (Data S1 ). Non-responsive cases were assessed through tele- phone interviews with horse owners. Subsequently, if no response could be obtained and if data were still missing, the horse was excluded from the study.
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