Special Flaps and Oral Nasal Fistulas

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

Sometimes these openings are large or easily seen as in the above images. Sneezing and occasional discharge are the common signs. Other times signs are subtler but systemic (body wide) effects are occurring without awareness.

Here is an inapparent oral nasal fistula:

They are not always this red.

This one is easier to guess an oral nasal fistula is present:

Tooth removed:

Unfortunately one can see the tissue quality is poor and doesn’t close easily. This is why the opening often happens. Special tissue flaps are created to close the defect to stop the communication between the nose and the mouth thus stopping subsequent infections. During veterinary dentistry residency training, we learn the periodontal classification as PE3 – a major flap procedure. Ie simple closure rarely is the solution due to local infection, tissue quality, and tissue quantity.

This video isn’t the best illustration but there is bone infection (osteomyelitis) and special techniques are need to close the defect:

Special flaps can be done for periodontal splinting, increased pocket depths, triangular gum recession – and much more. As long as there is sufficient healthy bone, we can save teeth with special flaps. Sometimes we can even add bone height with bone augmentation (guided tissue regeneration section) or Type II crown lengthening procedures. When teeth can not be saved, we have special flaps and techniques to return the mouth to a healthy state and avoid bone infection.

Contact us to learn more about saving teeth in pets.

Guided Tissue Regeneration

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

As the gum and bone surrounding the tooth margin (periodontium) have worsening poor health, extractions are often needed. These periodontal tissues usually have generalized disease and accompanying bone loss resulting in loss of tooth support. Other times the tooth has focal disease for which therapy can be successful in saving the tooth.

Vertical bone loss is a case in which deep pockets exist with supporting bone. A standard dental cleaning procedure cannot adequately clean deeper than 5 mm. The other concern with pockets greater than 3mm is that there is gingival downgrowth commonly reestablishing active disease as soon as 2-14 days after a cleaning procedure. Home care (daily or every other day) and anesthetic dental procedures (as often as every 3 months) can delay this process if it can get into the pocket but the pocket depth often prevents it. The solution becomes to surgically reduce the soft tissue pocket or, as pictured above, utilize a bone graft and biocompatible membrane to exclude the soft tissue from a bony pocket. The membrane is the most important feature to prevent tissue downgrowth perpetuating a pocket.

Here’s a hidden pocket:

Here’s the diseased tissue in the pocket removed:

A graft and membrane are needed/were used.

Contact us to learn more about saving teeth in pets.

Enamel Defects

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

The above image explains enamel defects well.

Some cases of enamel hypomineralization appear as discoloration. While this is not only cosmetic, it is important to help seal any access to the central aspect of the teeth.

Other cases have focal defects.

Once the defects have been sealed, the restorations will wear away as they are not as strong as natural enamel and there are inherent defects in the patient’s underlying tooth quality. In most cases, restorations can and should be reapplied.

Just as noted in other reasons for restorations such as caries and uncomplicated crown fractures, x-rays are needed before a restoration is applied and 6 months later. These patients, as well as every pet, should have intraoral x-rays with preventative cleaning procedures at least every 12 months.

Contact us to learn more about restorations in your pet.

Dentigerus Cysts

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

The above image explains dentigerous cysts well. It is important to remember unerupted teeth and retained tooth roots both are likely to cause problems. If you notice a tooth that does not have a matching tooth on the other side, make sure to ask your veterinarian to check it with intraoral x-rays. Should you own a breed with a short nose aka brachycephalic, missing teeth on both sides is more likely a problem thus may be easily overlooked. Please ensure your dog has full mouth intraoral x-rays or 3D imaging as it is shown intraoral x-rays reveal unexpected or additional new findings in 72% of dogs.

May be seen visually:

While an x-ray may look like this:

Contact us to learn more about dental care in your pet.

Extractions

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

The above image explanation sums up the need for extractions well. The strategic structural teeth (the canines and carnassials) should be saved instead of extracted as long as the gum and bone surrounding the tooth margin (periodontium) are adequately healthy.

This tooth has a draining tract:

Much surrounding bone has been lost due to disease (outlined in blue). As the gum cannot reattach without supporting bone and the space between the two roots has missing bone, extraction is the best choice even though this is a strategic tooth:

Dogs typically have 42 teeth and all but 8-10 have significant function. Teeth may be extracted as part of the therapy for a painful bite:

Tooth roots need to be removed in entirety (with the exception of replacement resorption) or may cause problems as shown below and in the baby teeth section.

Extraction of teeth can still leave parts behind, so an x-ray after extraction is necessary to ensure the extraction is complete.

Sometimes we take out teeth that are not yet diseased but will cause it (rotation):

Other times teeth have malformations requiring extraction:

When extracting teeth, there is risk of jaw fracture when appropriate anatomy and forces are not observed or when the bone health is compromised as imaged above. While fractures can be repaired, some conditions require bone grafts or special techniques. The goal with these techniques is to save structure and in some cases, preserve teeth:

When performing extractions, oral surgical techniques must be used to close the site (unlike common practice in humans).

Won’t a pet have trouble eating with missing teeth? Dogs and cats do fine with missing teeth, but an opposing tooth does not have the natural cleaning action and may perpetuate periodontal disease. A missing opposing tooth can also result in trauma to soft tissues. Sometimes this can be corrected with tooth shortening, other times extraction is again required. Exotics with continuously growing teeth that require extraction, the opposing tooth often needs extraction as well.

As mentioned in the stomatitis post, this situation usually needs caudal mouth or full mouth extractions. These patients usually benefit from a few days of tube feeding through the esophagus as the mouth heals.

Contact us to learn more about dental care in your pet.

Stomatitis

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

As mentioned in the previous post, tooth resorption is common in cats. Cats with stomatitis concurrently have tooth resorption and/or periodontal disease.

Should the inflamed ulcerated tissues NOT extend to the caudal aspect of the mouth (shown below), extractions in periodontally compromised and tooth resorption teeth should be performed.

Some cases of caudal mouth inflammation are mild:

All cases of caudal mouth inflammation require full mouth extractions (FME) including all retained roots. If the canines and incisors are unaffected, they may be retained, but every tooth and retained root behind the canines needs to be extracted. This is known as caudal mouth extractions (CME). Many patients with full/caudal mouth extractions benefit from a few days of feeding through a tube as the mouth heals. While all of these extractions sound radical, they are necessary. Patients without extractions such as this do not resolve, as this is a condition with an underlying immune system issue.

Approximately 70% of cats with FME or CME respond well with either complete resolution (1/2) or significant improvement (1/2) still requiring adjunctive medical management. Sadly ~1/3 of stomatitis patients do not respond well to any therapy. There may be a better outcome when extractions as first line treatment occur earlier in the course of disease.

Contact us to learn more about tooth resorption and stomatitis.

Tooth Resorption

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

Whole books could be written on tooth resorption (TR) alone.

Periodontal disease and tooth resorption are the two most common diseases in cats. Tooth resorption in cats has many names – kitty cavities, FORL, and more. The prevalence has been reported in different age groups ranging from 20-100%. One can say for certain that it is more prevalent in cats as they age (typically age 5+). One study showed 69% of mixed breed cats age 10+ had tooth resorption and 100% of pure bred cats age 10+ did as well. In the same study only ~ 20% of these patients had these findings on awake visual exams. Another study showed 2.4 times as many TR lesions were found on x-ray as compared to clinical exams.

Here’s an awake finding that is certain to have a painful process:

This one is similar and can be found awake but is more easily missed:

The x-ray of this site under anesthesia:

Revealing a focal ‘black’ spot of tooth (inflammatory tooth resorption) and loss of architecture of the root on the left (replacement resorption). A modified extraction technique (MET) can be used for the root on the left so that the remaining parts are below the gingival margin, but the root on the right must be removed in entirely or will continue to cause problems. Fragments of roots not having replacement resorption (aka retained tooth roots (RTR)) will not resorb. Tooth resorption is a painful often hidden disease usually happening along with periodontal disease. It is important to ensure your veterinarian uses intraoral radiographs or detailed 3D imaging for all cat dental procedures, as TR is not confined to the crown, but in fact, is a generalized recurring process. As stated above, due to the increased incidence of tooth resorption when inflammation is present, when you treat TR through extraction of teeth you slow the recurrence.

Some cats have canine teeth that are being extruded:

It is important to evaluate the whole mouth with intraoral x-rays in all of these cases as there is a significant correlation between extrusion of canine teeth in cats and tooth resorption. Other symptoms one may see on awake oral exam are buccal bone expansion (BBE) – this is enlargement of the bone usually surrounding the canine teeth in cats. (Green arrow)

83% of BBE biopsy sites showed tooth resorption, another reason to ensure cats have the entire mouth evaluated with intraoral x-rays as well as probing for periodontal health measurements. Cats with tooth resorption can also have inflammation in the back of the mouth (caudal stomatitis):

This condition is painful and medical therapy alone will not solve the problem. Check out the stomatitis blog post to learn more.

In some cases, tooth resorption in cats and dogs are similar, but more likely they are different.

Dogs are more likely to get external root resorption:

This condition is the exception to the extract right away rule. This type of resorption tends to not be painful until it involves the pulp (but then it’s no longer external root resorption) or extends above the gumline. Should probing depths or tooth contour become abnormal, extraction then becomes needed.

Other less common findings are internal resorption:

This problem is painful and requires extraction; we cannot watch and wait.

Tooth resorption can also occur uncommonly in exotic cheek teeth. Most of the time, the occlusal table needs to be equilibrated (aka floating teeth in horses), and the tooth will continue to erupt resolving the problem with frequent occlusal adjustments.

Contact us to learn more about tooth resorption.

Cavities in Dogs

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

A soft indentation or ‘pit’ is the most likely finding. One of the first steps in the restoration process is to remove the diseased tooth material (dentin). Some dark soft spots are not these ‘cavity’ type lesions, but instead visual diseased pulp. Restorations alone are not appropriate therapy for endodontic (inside of tooth) disease. Should the disease or cleaning process progress to the pulp (inner most layer of the tooth), the tooth would require root canal therapy or extraction.

Check for soft spots:

Special techniques are used to clean the defect. Certain materials are suited for the pressures of chewing, while others are not. Restorations require a curing light and smoothing instruments for each layer.

Contact us to learn more about restorations for your pet.

Cleft Lip, Cleft Palate

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

Clefts of the lip and/or palate have been reported to occur in ~1 for every 1000 live beagle births. Due to the fact many puppies with clefts are euthanized early in life the true incidence across breeds is unknown.

Surgeries to repair clefts are varied, but can be successful. Due to an average of 1.75 additional cm of bone is missing on average under the visible soft tissue cleft defect, 1) repairs may require multiple surgeries and 2) 3D imaging is invaluable.

Studies have shown animals with clefts have at least one additional anomaly such as ear issues or nasal issues. 3D imaging is necessary to find the additional issue as a study without CT found only 13.5% (vs 100%) had additional abnormalities. Just because a facility has CT imaging, it does not mean the detail is adequate for accurate diagnosis and treatment. Please ensure micro CT imaging is available. The imaging available in our facility is 3D cone beam computed tomography containing soft tissue as well as bone algorithms with true data instead of interpreted data. The detail is as thin as 0.09 mm and uses less radiation. Most traditional CT units use about twice as much radiation and have typical slice thicknesses of 4-6 mm = 20+ times less detailed.

Surgery can interfere with growth if performed anytime prior to 16 weeks of age. Many cases may need to find alternate feeding methods such as orogastric tubes until they reach sufficient age.

Contact us to learn more about cleft repair for your pet.

Jaw Fractures

As described in a recent post, dental conditions are often hidden and painful. The following posts are going to help describe conditions that pets can get as well as treatment. Many people I talk with are surprised how we can help pets with dental conditions and save teeth whenever possible.

As stated above, oral trauma should be corrected through non-invasive methods to save teeth whenever possible. Most training programs for boarded veterinary surgeons do not teach wiring and acrylic methods of correcting jaw fractures as seen below:

It is necessary to watch were the teeth contact and prevent the acrylic from contacting the gum tissues.

Wires may be used adjunctively to help in other areas of the mouth:

I urge extreme caution with fracture repairs in many general practices. Far too frequently, fracture repairs fail due to gum and/or bone infection that was present prior to fracture or occurred secondarily to improper technique.

Repairs of the jaw by a veterinary dentist allow for follow up root canal therapy when indicated. Sometimes parts of teeth can be removed while others saved (hemisection). In all cases, keeping the structural teeth (canines and carnassials) when possible is best for the patient.

Cats are more likely to fracture the front and back parts of the jaw:

Studies have shown 1.6 to 2 times as likely to find additional injuries with 1mm or less CT slice images for cases of trauma. 3D imaging is needed for all fracture patients. TMJ imaging is performed as part of this scan. Just because a facility has CT imaging, it does not mean the detail is adequate for accurate diagnosis and treatment. Please ensure micro CT imaging is available. The imaging available in our facility is 3D cone beam computed tomography containing soft tissue as well as bone algorithms with true data instead of interpreted data. The detail is as thin as 0.09mm and uses less radiation. Most traditional CT units use about twice as much radiation and have typical slice thicknesses of 4-6mm = 20+ times less detailed.

Be cautious of symphyseal separation and normal laxity in a cat. This is one possible ‘fracture’ that may truly not be. Here is a video of normal wide symphyseal movement in a cat. Intraoral radiographs or 3D imaging need to be used to help check for the need for repair. How the mouth closes, patient history, and concurrent disease are also use to help guide treatment decisions.

Contact us to learn more about fracture repair for your pet.