Archives for Dental Care

Dentistry – What a Pain!  Part 2

By Erika Ball, DVM

If you read our last discussion, you learned some shocking facts about the lack of dentistry training in veterinary medicine as well as how anesthesia is necessary for proper dental cleaning.  We also discussed ways in which anesthesia can be made significantly safer by following some simple principles.  This discussion will go more into depth about the dental procedure itself.

When you go to the dentist they take x-rays of your teeth before making any final decisions about tooth extraction.  If they don’t you should really consider a going to a different dentist.  More and more we are applying these same principles to veterinary dentistry.  It is now considered to be malpractice to perform dentistry on a pet without the benefit of dental x-rays.  Yet, fewer than 30% of veterinary practices even own a dental x-ray, let alone use it.  This is a completely different piece of equipment than your traditional x-ray machine that most practices have.  Dental x-ray equipment also comes with a considerable price tag, which helps explain why most practices don’t have it.  There is also a steep learning curve involved in taking and interpreting dental x-rays, and without proper formal training (not just what the sales rep gives you in 1-2 hours), it can be frustrating to the average vet.  This may result in leaving the x-ray unit unused, sitting in a closet.  Every pet should have a full set of x-rays taken at the time of the dental procedure, not just of those teeth that are suspicious on oral exam.  Many diseases of the teeth occur below the gum line where you cannot see with the naked eye. Without x-rays you are missing significant disease that needs to be addressed.  X-rays should also be taken following any extractions to be sure that no tooth roots are left behind.  Unfortunately this problem is all too common, especially in cats, who have extremely fragile teeth.

Nerve blocks should also be performed to lessen the pain experienced by the pet.  This also allows us to administer a lower level anesthesia, which in turn makes the procedure much safer.  This requires training and practice to perform correctly and effectively.  

Finally, the extraction process itself – This is a procedure that only a veterinarian with proper training should be performing.  It is illegal to allow any other staff including technicians, to do this.  Despite this law, it is an extremely common practice for technicians to be extracting teeth, often without any supervision by a veterinarian.  I will be the first to admit that when I started doing dentistry I didn’t have a clue what I was doing.  I used to dread it, because deep in my heart I knew there was probably a better way.  The problem is, if you read my first article, cats hide evidence of pain.  They will eat despite having painful teeth and will continue to do so even after improper extraction techniques that result in painful retained roots.  You as an owner may never know if your cat’s (or dogs) dental was performed properly and that they may still be in pain.  Proper extractions involve creating gingival flaps and exposing the roots of the teeth to be extracted to lessen the likelihood of root fracture (it is especially easy to fracture roots in cats!).  Once the tooth (or teeth) are extracted X-rays should be taken to verify complete removal of the roots.  The gingival flap is then sutured closed to prevent a painful condition known as dry socket.  Now, with multiple training courses, shadowing veterinary dentists, and years of practicing these learned techniques, I love dentistry.  It is the single most rewarding thing that I do that I know results in an improvement of my patients’ quality of life.  When these patients come in for their rechecks 2 weeks post oral surgery my owners tell me that their cat seems much happier, more playful, many times doing behaviors that they haven’t done in years!  Previously we may have chalked up some of those common “slowing down” behaviors to part of the aging process, when all along it was likely dental pain contributing to those behaviors.

You are probably wondering, “But how will my cat eat without teeth?”.  A valid question for sure.  The answer is that they may even eat better because it no longer hurts to do so.  I have patients that have no teeth at all that refuse to eat anything but dry cat food, and they manage just fine.  I also have patients that continue to hunt and kill mice with little to no teeth.

Since I deal exclusively with cats, any dental discussion that didn’t involve the most common dental problems that this amazing species suffer from would be incomplete.  The most common problem we see is tooth resorption.  This is a condition that can strike just about any adult cat.  In fact, 50% of all cats over the age of 8 have at least one tooth affected by tooth resorption.  There is much about this condition that we don’t understand.  We don’t even know the cause of it as of yet.  What we do know is that there is a type of cell, called an osteoclast, that begins to destroy the tooth.  This can start in the roots of the tooth or in the crown.  The result of this destruction is painful nerve exposure.  There is nothing that can be done to restore these teeth.  The only treatment is to extract the tooth to stop the pain.  X-rays are especially helpful in diagnosing this disease as often the roots are affected, but the crown may look relatively normal (so far, anyway).  X-rays also help us to determine the best approach to extracting the affected tooth.  

Periodontal disease is hardly exclusive to cats, but also very common.  This is one condition that could potentially be prevented or at least slowed by regular cleanings and even home tooth brushing.  I do caution cat owners that the majority of cats will not tolerate this, and if your cat happens to have any painful lesions you may actually be inflicting pain on your cat.  Tooth fractures are also common, and if left untreated will likely lead to a tooth root abscess.  A newly fractured canine tooth may be saved through a root canal procedure, which can only be performed by a veterinary dentist, but these fractures are rarely discovered in time to save the tooth, resulting in the need for extraction.  Probably one of the most horrific oral diseases we see in cats is stomatitis.  It is characterized by severe and exquisitely painful inflammation affecting the entire mouth.  There are many potential causes of this disease, including bacterial or viral infections, or allergic conditions, but regardless of cause, many of these cats will require full dental extractions to relieve the agony that they are suffering as a result of this disease.  Once again, x-rays are essential to ensuring that no speck of tooth is left behind to maximize the success of the procedure.

What I will leave you with are questions that you should always ask before you schedule your pet for a dental:

• Is the person cleaning the teeth and taking the x-rays the same person that is responsible for monitoring anesthesia (it is impossible to do a good job at both simultaneously)?  
• Does every patient get an IV catheter and are they kept on fluids during the dental?  
• Is a breathing tube being inserted to keep oral bacteria and debris from getting into the airway?  
• Do you have dental x-ray equipment and use it to take full x-rays on every dental, pre and post extractions?  
• Will I be given a copy of those x-rays?  
• Who is performing the actual extractions?  
• Do you use nerve blocks?
• Do you use gingival flap techniques when performing extractions?  
• Do you suture closed the gum tissue post extractions as to not leave open sockets that lead to painful dry socket?

As I’ve mentioned, dentistry is my passion, and I could talk about it all day.  My goal was to have at least provided you with enough information about it to allow you to make educated decisions about your cats (or dogs!) dental health.  I hope I’ve accomplished that if nothing else.  Let’s make sure your cat isn’t suffering in silence.  Schedule a dental exam today.

Dentistry – What a Pain! Part 1

By Erika Ball, DVM

If I were to ask you what you thought was the most common surgical procedure that I perform at my hospital, what would you guess?  I’ve already given away the answer, but without that hint you likely would have guessed spays and neuters, am I right?  The fact is, the number of dentistries I do far exceeds the number of spays, neuters, and all other procedures that I do combined!  Pretty much all pets would benefit from dentistry at some point(s) in their lives. I am specifically a cat vet, but most of the principles I am about to discuss apply to both dogs and cats.

How much training in dentistry do you think veterinarians get in veterinary school?  Quite a bit, right?  That would be a logical answer, considering we do more dentistry than any other procedure.  I hope you didn’t bet any money on your answer, because you would lose.  The answer is, with few exceptions, little to no training at all in dentistry.  I think I watched a dental cleaning once in vet school.  We spent more time on diagnosing oral tumors than routine dental cleanings and extractions.  Now Imagine you have a toothache.  Do you go to your primary care physician?  Would you let them extract it or would you rather be sent to a dentist or oral surgeon for that?  The human dentistry field originally developed as an off-shoot of general medicine as it required a considerable amount of training above and beyond what is taught in medical school.  The same applies to veterinary medicine.  If you are a graduate of veterinary school, and want to perform dentistry properly, you must seek additional training.  There are boarded veterinary dentists, for sure, but they are few and far between, and may not be an feasible option financially or locally for many pet owners.  It is up to veterinarians to seek that additional dental training post graduation in order to do right by our patients. Everything from recognition of various dental lesions and diseases, taking and interpreting dental x-rays, performing nerve blocks, to proper treatment and oral surgery techniques needs to be learned, as none of this is even discussed in most veterinary schools let alone practiced. Unfortunately the majority of vets never seek out that training, and more concerning is that they may not even realize that they need it.

Let’s talk a little about anesthesia first.  In order to properly clean a pet’s teeth, measure periodontal pockets, clean out bits of tartar that have extended underneath the gingiva, take x-rays, and ultimately perform extractions, the pet MUST be under general anesthesia.  This is for the safety of both your pet and the personnel performing the cleaning, as well as for the thoroughness of the procedure.  Don’t be fooled when your groomer tells you that they’ve cleaned your pets teeth.  They may look nicer externally, but ultimately hasn’t doesn’t your pet any good.  They are most certainly not cleaning up under the gumline, nor are they cleaning the inside surfaces of the teeth.  In addition, sometimes removing that tartar exposes painful and diseased teeth which can cause further pain.  Sharp instruments are frequently used to clean teeth, and if your pet moves during this process it can result in a laceration of the gums or worse.  Many people are afraid to put their pets under anesthesia, which is understandable.  Anesthesia is not without risk, and should always be taken seriously.  Prior to anesthesia your pet should have a thorough exam, have a blood work panel performed to screen for diseases that may increase the risk of anesthesia.  I also routinely recommend running a relatively new test that can screen for hidden heart disease, which can be a big problem in cats and can significantly impact your cat’s risk for anesthesia.  In some cases an ultrasound of the heart should also be considered prior to anesthesia.  Anesthesia, when performed properly, especially with the appropriate pre screening tests, is actually quite safe.  In order to induce and maintain anesthesia safely each pet should have an IV catheter through which fluids, and emergency drugs (if needed) can be administered.  The administration of intravenous fluids during anesthesia is essential for maintaining a normal blood pressure to protect your cat’s vital organs.  They should have a preanesthetic mixture consisting of small amounts of several different sedating medications, as opposed to a large amount of a single drug.  Pain medication should always be included in this combination, as preventing pain is much more effective than trying to address that pain once it arises.  Next an inducing agent is given.  Once anesthesia is induced with this fast acting and rapidly eliminated agent, a breathing tube should be placed and your cat is maintained on gas anesthesia.  This breathing tube also allows administration of oxygen and prevents the debris, fluid and bacteria from the mouth from entering the airways.  There should be a dedicated and properly trained technician present to monitor the anesthesia at all times.  Monitoring equipment should include multiple factors and parameters, including ECG readings, temperature, oxygen saturation of blood, blood pressure, heart and respiratory rate, etc.  This should not be the same individual that is cleaning the teeth and taking x-rays.  You cannot effectively monitor anesthesia while simultaneously performing these other tasks.  Anesthetic emergencies and death rarely occur without some advanced warning, but you need to be actually monitoring the anesthesia in order to pick up on these warnings.  There is so much more about dentistry that I want to discuss with you, so this article will be a two-parter.  Stay tuned for part 2.