Brushing your pet’s teeth may seem like the impossible dream at first, but it is the most important thing you can do for you pet’s oral health.  After all they have the same dental problems that we have and many of these can be prevented by routine brushing.

Dental disease is not only a problem in the mouth, it affects the health of the entire body.  Bacteria from oral disease travel in the bloodstream to the heart, liver, and kidneys and cause disease there as well.

When first starting your brushing routine, begin with the toothpaste by itself.  Use a pet toothpaste, not a human tooth paste.  A pet will swallow anything you put in its mouth and human toothpaste contains detergents that can upset the stomach if swallowed.  Pet toothpaste is flavored with a taste that your pet will like.  This is half the battle.

When you begin, leave the brush alone for a while.  Place a glob of toothpaste on your finger and gently rub it all around the pet’s mouth.  Do this every day.  This will slowly accustom your pet to having its mouth handled and get them used to the idea.  Be gentle and go slowly.  Don’t scare them and don’t hurt them.  They like the taste and will look forward to this daily event.

After a few days or weeks, try the brush.  Use a brush with soft bristles that will slide underneath the gingival margin.  This is where the nasty plaque lives that causes periodontal disease.  Keep the mouth closed, otherwise you will have a battle on your hands.  Slide the brush in between the lips and the teeth, holding the brush at a 45 degree angle to the gumline and make circular motions all the way back.  Do the same with the lower jaw.

The lower jaw presents a special challenge in the molar region.  Here the upper teeth overlap the lower teeth and the mouth will need to be opened slightly to access this area.  Some people will place a small chew toy in the front of the mouth to hold it open during this part of the procedure.

Back to top

ROOT CANALS AREN’T JUST FOR PEOPLE 

Jennifer brought “Buster” to our hospital because one of his teeth “just didn’t look right.”  Buster had fractured his upper left 4^th premolar, the largest tooth in his mouth, and one of the most important.

“Does Buster get bones to chew on?” I asked.

“Why of course”, Jennifer said, “I thought they were good for keeping the teeth clean.”

“They may help keep the teeth clean, but bones are the usual offenders with a broken tooth.  In fact, they keep me in business.”

When choosing a chew toy for your pet, make it pass a test first.  If you cannot place a dent in the toy with you thumbnail and you cannot bend it, don’t give it to your pet.

Buster’s tooth fracture had exposed the pulp chamber where the nerves and blood vessels live.  This allows bacteria to pour inside the tooth, causing pulp infection and necrosis, resulting in an abscessed tooth. 

Jennifer had two options for treatment of Buster’s tooth:  extraction or root canal.  Extraction would certainly get rid of the infected tooth and Buster could live without it.  Extraction, however, is a much more invasive and painful procedure, and with a root canal, Buster would still have his tooth to chew with.  Buster is a member of Jennifer’s family and she wanted only the best for him, so she chose the root canal.

We performed root canal therapy on Buster’s tooth the same way your own dentist does one on you.  In fact, we used the same instruments, materials, and techniques.  First we removed the infected pulp tissue and sterilized the root canals.  Next we placed a sealer in the canals to line the walls.  We filled the canals with gutta percha, a rubber-like material, to fill the empty space and help prevent bacterial leakage.  We placed a restoration to close the opening in the tooth.  A resin sealer on the restoration was the final step and served as one more barrier to leakage. 

Buster went home the same day and began using his refurbished tooth the next day.  Jennifer is controlling Buster’s environment so he cannot break another tooth or break the same one again.

When Buster fractured his tooth, the pulp chamber was exposed.  Some fractures do not directly expose the pulp, but instead remove the enamel layer and expose the dentin.  Dentin, which makes up most of the structure of the tooth, is a porous material, much like a sponge.  Numerous dentinal tubules (30-40,000 per mm ²) communicate with the pulp and allow bacteria to invade it.  So, we don’t need a pulp exposure to cause an abscessed tooth; all we need is exposed dentin.

Let’s take it a step further.  We don’t even need a fracture to cause pulp necrosis.  All we need is trauma to the tooth which causes the pulp to bleed.  The bleeding causes the tooth to become discolored, resulting in a tooth that is gray or tan.  Dr. Fraser Hale did a study on these teeth and found that 94% are non-vital or dead teeth.  These teeth also need either extraction or a root canal.

When Buster fractured his tooth, did Jennifer notice him showing signs of pain?  Not really.  She did think he might have been slowing down a little, but he is getting older and that’s what older dogs do, isn’t it?  Why didn’t he show obvious signs of pain?  After all, his nervous system is the same as ours and his teeth are made of the same tissues, only the shape is different.  Surely he must have felt pain.

The answer lies in Buster’s heritage.  Historically, Buster’s ancestors were predators, and as such, had to kill their food every day.  They were in constant competition with their colleagues.  If they ever showed weakness, and pain is a type of weakness, they ended up at the bottom of the food chain.  So our pets are genetically hard-wired to tough it out and never show signs of pain.  We do see evidence of pain retrospectively.  That is, after we remove pain by doing a root canal, the owner notices that the patient feels much better.  Sure enough, Jennifer called a week later to tell us that Buster was behaving like a puppy again.

Back to top

Periodontal Disease

Dental Pain 

Do our pets feel dental pain?  Absolutely!  Our pets’ nervous systems are the same as ours.  The composition of their teeth is the same, only the shape is different.  We can, therefore, assume that they feel oral pain in the same manner that we do.   

Why don’t our pets reveal clear evidence of dental pain?  First, they are much more stoic than we are.  They are survivors and do whatever it takes to make it through their daily lives.  Our pets rarely miss a meal due to oral discomfort.  When a patient is presented with the complaint of decreased appetite, look for systemic disease, as the cause is seldom found in the oral cavity. 

Historically our pets’ ancestors were predators, killing their food every day for survival, and competing with their colleagues for this food.  If a predator demonstrates any weakness to his fellow hunters (and showing pain is showing weakness), he suddenly becomes prey and falls to the bottom of the food chain, becoming nourishment for his rivals.  Our pets, therefore, are genetically hard wired to conceal weakness and pain. 
 

How do our pets demonstrate oral pain?  Very subtly.  They may chew their food on one side of their mouth, drool, or rub their face on the floor or with their paw.  Sometimes they simply decrease their activity level almost imperceptibly.  Many of these pets are aging animals, and the owner expects them to slow down as part of their normal routine.  This subtle behavioral change is accepted as normal. 

When you lift the lips of your patient, compare the accumulation of calculus on each side of the mouth.  If one region has greater accumulation than the other, this is a red flag.  This side may have an area of pain causing the patient to favor it by chewing on the opposite side.  The side with less chewing will accumulate more calculus.  We must pay particular attention to this area, searching for the source of pain. 

Our payoff comes when we remove the source of pain from our patient, whether it be by performing a root canal procedure, treating periodontal disease, or extracting an abscessed tooth.  After we remove the pain, our patient frequently has a dramatic behavioral change.  The owner often calls a week later, happily proclaiming that, “Fluffy is acting like a puppy again!” 

Remember, it is our duty to be the patient’s advocate and remove pain, whether the owner is aware of it or not.

Back to top

Fractured Teeth

Fractured teeth are among the most common types of oral pathology that we see in our practice.  They may be classified by cause, severity, or location within the mouth.

Teeth residing in the front of the mouth, the canines and incisors, are usually damaged by external blunt trauma.  This may result from two pets roughhousing and clashing their teeth together, running into a stationary object such as a tree or boulder, or becoming the recipient of an errantly tossed baseball or rock.

The premolars and molars farther back in the mouth are usually fractured by chewing on an object that is harder than the teeth.  (1)Such objects include bones, cow hooves, rocks, “bully sticks”, hard nylon chew toys, and pressed rawhides.

The severity of the damage varies considerably, but can be characterized by the presence or absence of a pulp exposure.  A shallow fracture will not expose the pulp of the tooth, but will nearly always remove the thin (0.3 mm) layer of enamel and expose the next layer, the dentin.  (2)Dentin makes up the majority of the structure of the tooth.  Dentin is interlaced with a network of dentinal tubules with a density of 30-40,000 tubules per mm2.  These tubules communicate directly with the pulp of the tooth and contain nerve endings extending out from the pulp.  Exposure of these nerves causes sensitivity.  More importantly, these tubules provide a pathway for bacteria from the oral cavity to travel into the pulp and cause pulpitis and pulp necrosis. (3)

A more severe fracture will create a direct exposure of the pulp of the tooth to the oral environment.  This creates a direct access for bacterial invasion of the pulp.  Once bacteria have invaded the pulp, through either a direct or indirect pulp exposure, the result is the same.  Pulpitis, an inflammation of the pulp, is usually irreversible and leads to necrosis, or death of the pulp.  If untreated, an abscessed tooth will result.

Treatment of fractured teeth depends upon the severity and duration of the fracture, the age of the patient, and the presence or absence of a direct pulp exposure.

A tooth with a dentin exposure may allow bacteria to travel through the tubules into the pulp of the tooth.  The first step in treatment is to radiograph the tooth, searching for evidence that the tooth has already been infected.  If such evidence is found, it must be treated in the same manner as a tooth with direct pulp exposure.  If no evidence of pre-existing infection is found, our goal is to seal the exposed dentinal tubules to prevent bacterial invasion into the pulp.  This is accomplished with the application of a bonding agent onto the dentin.  A bonding agent is an acrylic, a liquid plastic.  This liquid plastic is applied onto the tooth where it flows into the open dentinal tubules.  A curing light is used to initiate a chemical reaction called polymerization, which transforms the liquid plastic into solid plastic plugs, thus sealing the openings of the dentinal tubules and preventing bacterial invasion.  In some cases a composite restoration is applied as well.

A tooth with a direct pulp exposure requires one of two treatment choices---extraction or endodontic treatment. (4) An extraction will remove the source of infection and as such, is curative.  Endodontic treatment, however, will preserve the tooth for future use and is much less invasive and less painful than extraction.

In a patient less than a year of age and a fracture with a duration of only a couple of days, we may choose to perform vital pulp therapy.  Vital pulp therapy keeps the tooth alive and allows it to continue to develop and grow in strength.  A few millimeters of pulp are removed with a sterile bur and medication is placed on top of the exposed pulp.  A composite restoration is placed in the fracture site, sealing the tooth from the external environment.

An older patient or an older fracture will require root canal therapy to save the tooth.  (5), (6)This procedure is the same as a root canal done by your dentist on one of your own teeth.  Files of increasing size are used to remove the infected pulp and shape the walls of the root canal.  The canal is sterilized to remove infection.  A pasty root canal sealer is used to line the canal, and the canal is filled with gutta percha, a rubber-like material.  Proper filling and sealing of the canal will ensure successful treatment.  A composite restoration is placed in the fracture site and the procedure is complete.

Fractured teeth are common in our pets and even a shallow fracture can lead to pain, an abscessed tooth, and infection in the rest of the body.  Check your pet’s mouth often so we can treat these frequent injuries as soon as possible.

Back to top

(1)

(2)

(3)

(4)

(5)

(6)

Dentistry Without Anesthesia

|2007 No Anesthesia Case Study pdf 286kb| |html|

“My neighbor told me she had her pet’s teeth cleaned by someone without anesthesia.  My Fluffy is 15 years old now and I am concerned about placing her under anesthesia to have her teeth cleaned.  Is it really necessary?”

Many pet owners have a fear of anesthesia and they will understandably seek out services that avoid that frightening aspect.  Veterinary anesthesia has changed significantly in the past few years and due to the current use of a balanced anesthetic approach and the use of multiple methods of pain management, the safety of anesthesia has improved dramatically.  At our office we routinely safely anesthetize dogs and cats that are in their late teens and early twenties. 

Placing dental patients under general anesthesia is necessary for two primary reasons----first for making a diagnosis, and second, for performing an effective treatment.

When a patient comes in for a dental prophylaxis or cleaning, the vast majority of pet owners assume that the procedure will only entail a cleaning. (1) The percentage of our cases that are “routine cleanings,” however, is about 10%.  This is because the incidence of dental disease is incredibly high.  Periodontal disease is the most common disease of any kind in the dog, cat, and human being.  It is impossible to look in a patient’s mouth in the exam room while the patient is awake and make an accurate assessment of its oral health.  Even with the level of training that I have had, I still emphasize to the pet owner that “the real exam begins under anesthesia.”  Once the patient is under anesthesia, we use a dental probe to probe the pocket depth at 4-6 locations around the periphery of every tooth in the mouth. (2) A cat has 30, a dog has 42.  We also search the mouth for gingival recession, gingival hyperplasia, periodontal disease, fractured teeth, enamel defects, malocclusions, oral neoplasia, missing teeth, supernumerary teeth, resorptive lesions, and retained deciduous teeth, just to mention a few.  This thorough exam often turns up problems that no one was aware of.  Human patients will tolerate such a thorough examination because they have an understanding of its importance.  Our patients will not cooperate without the aid of anesthesia.  (3)

A full 60% of oral pathology is hidden beneath the gingiva where it cannot be detected without the use of intraoral radiography.  Again, this cannot be accomplished without the use of general anesthesia. (4)

When performing a dental prophylaxis, it is mandatory to perform subgingival cleaning, either with hand instruments or with ultrasonic scaling.  The reason is that the plaque that causes periodontal disease lives under the gums.  In order to properly clean the subgingival areas we must have the complete cooperation of the patient, which requires general anesthesia.  (5)

As I mentioned, we often find dental pathology that needs to be addressed beyond  routine cleaning of the teeth.  Understandably, these procedures such as an extraction or oral surgery will require general anesthesia. 

Services that clean the teeth without general anesthesia cannot possibly do a proper job on their patients.  They are unable to remove subgingival plaque, the plaque that causes periodontal disease.  So, what do they do?  They remove the tartar or calculus that is visible on the crown of the tooth.  They remove the crud and make the teeth look visibly better.  They have not, however, done anything to benefit the oral health of the patient.  Nor have they done anything to detect further oral disease. This is merely a cosmetic procedure.  (6)

The patrons of such services have paid money for a cosmetic procedure with no oral health benefit.  But it is much worse than that.  The owner sees that the teeth appear cleaner and they feel good that they have done something beneficial for their pet.  They believe that their pet is now good to go another year without any dental care.  The subgingival plaque, however, is still sitting under the gingiva and still causing periodontal disease which will be worse next year.  The owner has been lulled into a sense of false security, unaware that the disease process is still ongoing.  In my opinion, this makes the procedure much worse than doing nothing at all.  When I discuss this scenario with my clients, I tell them that this is similar to a situation when your house is on fire.  You call the fire department.  They drive over and make the smoke go away.  Then they drive away and the fire is still burning.  The fire is still burning beneath the gingiva.

I can assure you that there is not a single member of the American Veterinary Dental Society, the Academy of Veterinary Dentistry, the American Veterinary Dental College, or the Academy of Veterinary Dental Technicians that feels that this procedure is a good idea.

I have posted numerous dental cases with photos, radiographs, and discussions.  Here is a link to a case that discusses this very situation:   December 2007.pdf

Back to top

(1)

(2)

(3)

(4)

(5)

(6)

We have all seen discolored teeth in our practices. Over the years we have had a tendency to avoid treatment of these teeth, but as we learn more about the pathophysiolgy of this condition we may change our perception and our approach to treatment.

There are various causes of discolored teeth, some of which are systemic in origin, such as ingestion of tetracyclines during tooth development. Systemic causes, however, usually affect all or most of the teeth in the mouth. We will restrict our discussion to cases that have a single tooth or only a few teeth affected. 

The primary cause of discoloration of a single tooth is blunt trauma. The trauma is not severe enough to fracture the tooth, but it is severe enough to cause pulpal hemorrhage. After this hemorrhage takes place, rupture of the erythrocytes occurs, freeing the hemoglobin into the pulp of the tooth. Disintegrationof the hemoglobin occurs, breaking it down into components such as hematoidin, hematoporphyrin, and hemosiderin. These products diffuse into the dentinal tubules and end up lying under the enamel layer. Enamel in the dog and cat is 0.3 mm thick and is quite translucent, thus the discoloration. The color may vary from pink to purple, from gray to tan.

Pulpal hemorrhage leaves another consequence in its wake: pulpitis. The pulp of a tooth lives in a very restricted space, confined by rigid dentinal walls. Hemorrhage of the pulp creates an increased hydraulic pressure on the pulp and this pressure leads to serious inflammation and often, pulp necrosis. Chemical inflammatory mediators such as cytokines and interleukins are released and lead to pain. 

Should the pulpitis progress to necrosis, the nerves within the pulp will no longer register pain. However, the chemical mediators will migrate through the apical delta (a network of channels in the apex of the root that carry the blood supply to the pulp), and diffuse into the periapical tissues that are still vital and fully capable of registering pain.

Pulp necrosis carries with it another liability, that of anachoresis. Anachoresis is the tendency for blood-borne bacteria to seek out necrotic and inflamed tissue for the purpose of establishing an infection.

Dr. Fraser Hale, a veterinary dentist in Guelph, Ontario, Canada, published an article in the March, 2001 issue of the Journal of Veterinary Dentistry concerning this very issue of discolored teeth. He performed a retrospective study of 84 discolored teeth and concluded that 92.2% of these teeth were suffering from pulp necrosis. Another interesting finding was that radiographic evidence of endodontic disease was absent in 42.4% of these teeth. Therefore radiographic examination of these teeth is not a valuable tool in diagnosing this disease. Dr. Hale recommends extraction or root canal treatment of all discolored teeth. 

Since this study was published I have followed Dr. Hale’s advice and have performed either extraction or root canal therapy on all discolored teeth that we have encountered. Evaluating a pulp during a root canal procedure is much more reliable than evaluating the pulp of an extracted tooth, so I have limited my evaluations to endodontically treated teeth.  Since my investigqation began in 2001, I have yet to find a discolored tooth that was not suffering from pulp necrosis.

Back to top

(1)

(2)

(3)