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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.

Uncomplicated Crown 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.

Tooth fractures are one of the most common dental problems seen in dogs. These fractures can be complicated (involving the pulp which is the center tooth nerves and blood vessels) or uncomplicated (break usually removing enamel, exposing dentin, but not pulp). Bones, antlers, hooves and anything without flex can break teeth. The FDA even put out a warning to this effect. Chewing on bones breaks teeth. Appropriate chews and toys are any object with flex. If your fingernail can indent the object, it’s okay. It’s even been reported for ice cubes to break teeth. In some cases, chewing is happening on objects such as kennel bars and other items that cannot be taken away. A lucky pet will have the dentin exposed but not pulp. Dentin exposure is painful. The odontoblastic processes (nerve endings) are exposed to fluid from the mouth. In addition to this pain, there is risk of infection.

To seal the tubules and improve cosmetics, a restoration can be performed.

On x-ray this recent tooth fracture was fine for the moment:

So a restoration was place to seal the dentin, stopping pain and new infection.

Because the trauma that caused the uncomplicated crown fracture may actually cause irreversible pulpitis or bacteria may already be in the dentin but has not shown up as infection, intraoral x-rays under anesthesia are needed in 6 months, then every 12 months there after. As every pet needs at least annual dental preventative care, the every 12-month evaluation should not be a problem. X-ray changes can lag behind disease occurrence by 4-6 months, as there must be enough mineral change to see the problem on x-rays.

Occasionally the body can form reparative dentin. Waiting for this to happen is not a good idea, but should a darker area that is not soft when pressed with a sharp shepherd’s hook probe be present, treatment of the uncomplicated crown fracture is not needed. X-rays to get a ‘snapshot’ of tooth health under the gumline is still needed.

Sometimes living/vital teeth are crowned to repair the damage and wear from kennel bars and/or uncomplicated crown fractures and give added strength for likely continued chewing.

Contact us to learn more about restorations and crowns for your pet.

Crowns

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.

Research shows that fractured and/or endodontically (having had root canal therapy) treated teeth are inherently more likely to break. One paper showed those treated teeth without crowns were up to six times more likely to break as compared to endodontically treated teeth with full metal crowns. The upper 4th premolar (shown above) is the tooth that is the weakest without a crown. Although full metal crowns are not required after a tooth receives root canal therapy, many choose to protect their investment returning the tooth to its natural original strength or stronger.

Due to the physics of chewing in dogs and the fact that we cannot simply tell them not to chew on hard objects, the crown must be made of strong materials. Our office uses titanium alloy crowns for patients. Some veterinary dentists are trying zirconium (very durable and closer to tooth color) crowns. Porcelain crowns do not seem to last in most dogs.

To allow the crown to fit, typically 0.7-1.2 mm of tooth is taken away with varying sizes and grits of diamond burs. The enamel of dogs is 0.1-0.6 mm thick meaning that only dogs that have sufficient dentin (usually by age 2) are good candidates for crowns. Additionally as long as there is sufficient tooth height in proportion to its diameter, broken teeth or discolored teeth having received standard or non-standard root canal therapy are suitable for crowns.

Bones, antlers, hooves and anything without flex can break teeth. The FDA even put out a warning to this effect. These are the primary causes for tooth breakage, root canal therapy, and subsequent full metal crowns. Appropriate chews and toys are any object with flex. If your fingernail can indent the object, it’s okay. It’s even been reported for ice cubes to break teeth. After root canal therapy, it is important to take away all items that can break this treated tooth as well as others. As many owners are surprised what their pet finds to chew on, having a full metal crown gives strength and peace of mind should that occur. Continued chewing can still dislodge crowns so removing non flexible chews/toys is still a good idea.

In some cases, chewing is happening on objects such as kennel bars and other items that cannot be taken away. Sometimes living/vital teeth are crowned to repair the damage and wear from kennel bars and/or uncomplicated crown fractures and give added strength for likely continued chewing.

Contact us to learn more about crowns for your pet.

Discolored Teeth

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 alluded in the image text above, almost all discolored teeth are dead. They are discolored because the breakdown of the contents of the pulp leeches into the dentinal tubules discoloring the tooth. This is not just cosmetic as my father was taught, but a painful process. These breakdown products are a great place for bacteria to colonize exacerbating the problem. The only choices appropriate choices are root canal therapy or extraction.

As seen in the image above and its accompanying x-ray, teeth age like inverse trees. Instead of laying down rings on the outer edge of the trunk, dentin is laid down inside the tooth adding structure and decreasing the pulp (tooth center nerve and blood vessels) diameter. When a tooth stops laying down dentin and similar teeth nearby do not, one sees a wider pulp chamber in the dead tooth. Other signs can be bone loss related to disease at the tip of the root, root resorption, or narrowing of the pulp cavity due to calcification. One research paper states that only 42% of discolored teeth have x-ray signs, meaning that around 58% are still necrotic but don’t have x-ray signs yet.

Another tool for evaluating a tooth to verify discoloration is called transillumination. It’s like candling an egg. A living tooth will have light shine through, while a dead one will not.

Although these images show obvious differences, it may not be this easy to tell. Transillumination alone cannot be used to make the judgment on treatment of a tooth. If one leaves behind a diseased tooth, the pet is left with pain or it will soon have pain at that site. There are systemic inflammatory effects (LINK to Increase Anes Safety on Advanced Dentistry page on fampetvet.com) known with diseases of the mouth, thus beyond pain, leaving behind disease is not wise. Extracting every affected tooth is preferable to leaving problems, but the most common teeth to become discolored are the canines and carnassials (the large important chewing teeth towards the back). There are a total of 8 of these structural teeth out of 42 total possible teeth in a dog’s mouth. The best course of action for the canines and carnassials is root canal therapy to save the structure and function but remove the pain and disease. One needs to be aware when deciding to extract these strategic teeth that they are losing almost all chewing function on that side of the mouth in the case of carnassials or removing a lot of jaw structure in the case of the canines. The most difficult tooth to extract in the entire mouth is a lower canine. This is one of the reasons that a common site for iatrogenic jaw fractures is adjacent to a lower canine extraction site. Root canal therapy must be considered, as it is best for the pet.

The exception to this discoloration discussion is reversible pulpitis. When a concussive force occurs to the body, usually a bruise is formed and resolves it. When a concussive force occurs to a tooth, if a pet were lucky enough to have a ‘bruise’ and still have the tooth continue to live, the breakdown products would still leech into the tubules discoloring the tooth. The veterinarian can prescribe antibiotics (amoxicillin-clavulanate or clindamycin) and non-steroidal anti-inflammatory drugs (provided the pet’s bloodwork is appropriate) for 7 days. If the tooth’s color doesn’t return to normal after two or three months, you can assume it’s irreversible discoloration (pulpitis) leaving the only appropriate choices of root canal therapy or extraction. If the tooth improves, it must be followed with intraoral x-rays in 4-6 months, then every 6-12 months. Continued discoloration is likely an irreversible process and 42% of the time x-rays will verify it. It does take 4-6 months for x-rays to show mineralization change, thus answers will not usually be known right away.

Contact us to learn more about root canal therapies in your pet.

Avulsed Tooth

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 in the image above, when conditions are right, it is possible to save teeth that have been ‘knocked out.’ It is VERY important to put the tooth in a glass of milk and drive promptly to a veterinary dentistry center. The less time out, the better. In all cases, the injury must have occurred within 24 hours. There are exceedingly rare cases of teeth being repositioned within 30 minutes after the luxation and the tooth becoming vital again.

The trauma causing this situation often occurs in dogfights or road accidents (HitByCar). Sometimes the tooth is moved to the side (luxation/subluxation). Other times the tooth is pushed inward (intrusion). In all cases, there needs to be enough supporting bone and no or very little infection surrounding the tooth to allow the appropriate healing.

The tooth is splinted and a follow up root canal therapy is performed one week later. Depending on each case, the splint may stay in place for up to four weeks, then removed. In all types of endodontics, it is necessary to follow up with anesthetic imaging of the tooth in 6 months, then every 12 months there after.

In this emergency case, call our office or an emergency clinic telling them of the urgency of this case (keyword avulsed) and they will call my cell phone so I can meet you as promptly as possible.