Dentistry Without Anesthesia
Brushing your petís teeth may seem like
the impossible dream at first, but it is the most important thing
you can do for you petís oral health. After all they have the same
dental problems that we have and many of these can be prevented by
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
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
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 petís 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.
Donít scare them and donít 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
Thatís all there is
to it! Studies have shown that brushing must be done at least every
other day to be effective and every day is even better. It only
takes a couple of minutes a day and is well worth the effort. Itís
all in the training. Once that part is accomplished, it is smooth
sailing. Good luck!
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ROOT CANALS ARENíT JUST FOR PEOPLE
ďBusterĒ to our hospital because one of his teeth ďjust
didnít look right.Ē Buster had fractured his upper left 4th
premolar, the largest tooth in his mouth, and one of the
get bones to chew on?Ē I asked.
courseĒ, Jennifer said, ďI thought they were good for
keeping the teeth clean.Ē
ďThey may help
keep the teeth clean, but bones are the usual offenders with
a broken tooth. In fact, they keep me in business.Ē
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, donít give it to your pet.
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
two options for treatment of Busterís 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 Jenniferís
family and she wanted only the best for him, so she chose
the root canal.
root canal therapy on Busterís 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.
home the same day and began using his refurbished tooth the
next day. Jennifer is controlling Busterís environment so
he cannot break another tooth or break the same one again.
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 donít need a
pulp exposure to cause an abscessed tooth; all we need is
Letís take it a
step further. We donít 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.
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 thatís
what older dogs do, isnít it? Why didnít 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 Busterís heritage. Historically, Busterís 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.
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Does your pet have
offensive breath? Are the gums red? Are the teeth
covered with brown tartar? If your pet is showing
any of these signs, he or she is probably suffering
from periodontal disease.
Periodontal disease is the most common disease of
any kind in the dog and cat. In fact, 80
% of dogs and 70 % of cats over two years of age
suffer from periodontal disease. The exceedingly
high incidence of this disease makes it imperative
that we look at ways to detect and treat it.
Periodontal disease begins with the accumulation of
plaque on the teeth. Plaque is a biofilm, which is
an accumulation of components that create a terrific
environment for bacteria to thrive in. Next the
bacteria create infection and inflammation in the
gingiva, periodontal ligament, and eventually the
alveolar bone surrounding the tooth. Attachment
loss develops, creating pocketing between the
gingiva and the tooth. Destruction of the
periodontal ligament and alveolar bone eventually
lead to mobility and loss of the tooth. This sounds
bad, but it gets even worse. Research has shown
that the bacteria involved in periodontal disease
migrate through the bloodstream and cause infections
in the heart, liver, and kidneys.
How do we detect periodontal disease in your beloved
pet? By regular dental examinations and prophylaxes
performed by your veterinarian. Most pets need
their teeth cleaned annually. It is impossible to
accurately evaluate your petís oral health, clean
the teeth, or treat periodontal disease without the
benefit of general anesthesia. With the advent of
pre-anesthetic bloodwork, safely balanced anesthetic
protocols, and intensive anesthetic monitoring and
supportive procedures, most of the fears of
anesthesia have been allayed.
A thorough oral examination includes probing of each
tooth in the mouth to detect any pocketing or
attachment loss. Any abnormal findings are recorded
on the patientís dental chart.
The most important diagnostic tool we employ for
detection of dental disease is dental radiography.
Sixty per cent of dental pathology hides beneath the
gums and will remain undetected without the use of
How do we treat periodontal disease? Treatment
depends upon the stage of involvement. Gingivitis,
which is the first stage of periodontal disease, is
treated by a thorough cleaning, both above and below
the gum line. It is absolutely essential that the
subgingival plaque be removed. Otherwise the
procedure becomes merely cosmetic in nature.
requires subgingival curettage to remove the
infected material. After curettage, we infuse an
antibiotic gel called Doxirobe into the pocket. The
gel slowly releases the antibiotic into the infected
periodontal tissue over a period of 3-4 weeks. This
can be a very effective treatment. Deeper pockets
with bone loss require periodontal surgery. A
periodontal flap is created for exposure and the
infected tissue is removed. Next a synthetic bone
graft is placed into the bony defect and the flap is
closed with sutures. After 4-6 months the defect
has healed through the process of bone
What can you do at
home to prevent periodontal disease in your pet?
Daily brushing is the best thing you can do.
Research tells us that brushing must be done at
least every other day to provide any significant
benefit. The key to successful brushing is making
it a pleasant experience. Use flavored toothpaste
designed for pets, and go very slowly at first. Do
not hurt them or scare them and your persistence
will usually pay off. If brushing is not an option,
you can use a product called Oravet. This is a waxy
barrier applied to the teeth to protect them from
is a very common and dangerous malady that can occur
in each of our pets. We owe it to them to have
regular checkups and cleanings to prevent and treat
this potentially devastating disease.
Dr. John Koehm is
co-owner of Community Animal Hospital, a six doctor
hospital providing services in general medicine and
surgery, advanced dentistry, advanced
ultrasonography, endoscopy, laser surgery, and
medicine and surgery of exotic species. Dr. Koehm
is a Fellow of the Academy of Veterinary Dentistry
and his professional activities are limited to
dentistry and oral surgery.
Do our pets feel
dental pain? Absolutely! Our petsí 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 donít 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.
petsí 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
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, ďFluffy is acting like a puppy
Remember, it is our
duty to be the patientís advocate and remove pain,
whether the owner is aware of it or not.
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, ďbully sticksĒ, 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)
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
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.
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.
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
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
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 petís mouth often so we can treat these
frequent injuries as soon as possible.
Dentistry Without Anesthesia
No Anesthesia Case Study
neighbor told me she had her petís 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?Ē
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
dental patients under general anesthesia is necessary for
two primary reasons----first for making a diagnosis, and
second, for performing an effective treatment.
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 ďroutine cleanings,Ē 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 patientís 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 ďthe real exam begins under
anesthesia.Ē 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)
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
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.
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
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.
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.
posted numerous dental cases with photos, radiographs, and
discussions. Here is a link to a case that discusses this
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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
Since this study was published I have
followed Dr. Haleís 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.
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