Dentistry

You’ve heard it from your veterinarian plenty of times. “Your dog or cat has tartar on its teeth.” “You should brush your pet’s teeth.” “We should get your pet started on some dental chews.” “We should think about getting Cuddles in for some dental work.” We mean it but at some point we just fail to really push the importance of keeping good dental care as a priority for your pet. Your pet’s mouth is the major way they communicate with the world around them. They use their mouth when they play, for defense, when they are exploring new objects and when they are eating. An animal with a painful mouth is not going to have the same quality of life as they would if that mouth were pain free. I think everyone can agree with that assessment when it comes to dental care in pets. Where the major disconnect in communication seems to be lately is in the understanding of what happens during a “dental” in the veterinary hospital setting.

The term dental can mean a lot of different things. In the case of an animal with a healthy mouth that needs some scaling and polishing this would be called a “prophy.” Short for prophylactic this procedures is a preemptive strike against periodontal disease. If we were to go in and clean and polish the teeth and then realize that there were some questionable teeth that may need to be removed this becomes a surgical procedure. The difference between the two can be measured in hours of time spent working in the mouth and in hundreds of dollars.

Every pet having dental care at our hospital is going to be placed under anesthesia. This is for three major reasons. The first is fairly straightforward, your pet can not understand what is happening to them and will not hold still to allow us to perform a technically difficult procedure inside their mouth. Without anesthesia the dental work being performed is going to be sub par and in most cases will do more long term harm then good. The second reason we use anesthesia is because of the nature of tartar in a pet’s mouth. Dental calculus is a calcium composite produced by bacteria in the mouth. When the teeth are scaled this bacteria is taken off the teeth and ends up in the mouth, on the table and in the air. When a patient is anesthetized they have an endotracheal (inside the trachea) tube that delivers the anesthetic gas mixed with oxygen. This tube has a small cuff that inflates to provide a gentle but airtight seal. The cuff prevents any of that bacteria from entering the airway and setting up a potentially life threatening pneumonia. The third reason we place animals under anesthesia for dental care is because it hurts! The calculus is most abundant at the base where the gums meet the tooth. In attempt to prevent further build up and a life threatening infection the gums become inflamed and bring blood and the bacteria fighting cells in the blood to the area. When we go in to physically clean the tartar off the teeth we have to clean above the gum line. Moving a scaler above inflamed gums is very painful and doing this in a patient that was not anesthetized and did not understand the procedure would be unfair.

Let’s walk through a dental procedure that includes several extractions. Each patient’s mouth is examined while they are still awake. Sometimes we will then call the owner and let them know what we expect to find. This is especially true if we have never seen the patient before or if we expect there to be a lot of extractions. It can be tricky giving the owner a first assessment because there can be a huge difference between the mouth a dog will show you awake and the mouth you find under anesthesia. The patient is then anesthetized and placed on their side. An overview of the mouth is performed and an initial treatment plan is formulated. The calculus or tartar is de-bulked using an instrument that looks similar to the crackers used on crab or lobster claws. Once the bulk of the tartar has been removed a new plan is formulated. The teeth are cleaned with an ultrasonic scaler and hand scaling until there is no visible tartar. They are also scaled above the gum line (60% of dental disease occurs above the gum line) and at this time the teeth are evaluated for pockets and loss of attachment. Once the teeth are completely scaled a dental probe is used to evaluate the teeth and gums and to determine whether or not we need to move to the next step, extraction. If the mouth is healthy this is where we would stop, polish and wake the patient. This would be a “prophy.”

If the mouth is not healthy we need to make some decisions. The best way to decide whether or not a tooth needs to be taken out is use the evaluation arrived at with the scaler and probe and compare that to a dental  x-ray. Remember I said 60% of the disease occurs above the gum line where we can’t see. Sometimes there will be bone infection and loss of jaw bone present in otherwise healthy teeth visible on x-rays that we might have missed otherwise. With the information from the x ray we can then decide which teeth need to be removed and which teeth should be left alone. The technique used in removing teeth varies depending on the tooth that requires extraction. For our example, let’s pretend we are removing a Canine tooth (on of the 4 long thin teeth towards the front of the mouth) and a Carnassial tooth (one of the big scissor like teeth in the back of the mouth.) To remove the canine tooth we use instruments that resemble chisels known as elevators to gently pull the gingiva (gum tissue) away from the tooth on all sides. Often times a scalpel will be used first to incise the periodontal ligament and ease the elevation of gingiva. Once all the gingiva has been properly elevated we sometimes make two small incisions into the gingiva on either side of the tooth. Sometimes we make one incision and often we try not to make any incisions. This flap of tissue is pulled back to reveal the tooth to the root. The tooth is then gently removed from its socket using the elevators. To remove the Carnassial tooth we will also elevate the gingiva away from the tooth and sometimes make a gingival flap by making incisions into the gingiva but in these cases we often need to cut the tooth into segments before we remove it. This is done using a dental drill. We typically split the tooth between each of the three roots and then using the elevators we will remove the tooth from the socket one root at a time. The socket is thoroughly cleaned and reevaluated and any bleeding is topped. The patient will now have a second dental x ray taken to be sure that we did not leave any bits of teeth behind as left behind pieces of tooth root may cause a problem in the future. As long as the x ray is clear we can close the holes we left behind using the gingival flaps we made. In the Canine sockets I typically pack a bone matrix into the hole left behind to accelerate healing and minimize bone loss (which causes loss of structural integrity) for the jaw. In the Carnassial tooth socket I will actually clip some of the bone away before packing the site with bone matrix. I then suture the gingival flaps over the extraction sites. The remaining teeth are then polished and the patient is recovered from anesthesia.This is not a “prophy” but would be considered dental surgery. The next dental this dog or cat has may in fact be a prophy so long as it is done in a timely manner.

Most dogs do better after removal of offending teeth. They are less painful and return to life as normal within a few days. The exception being full mouth extractions, these dogs and cats (usually cats) may take a few extra days to recover but when they do their lives are much improved. Unexpectedly, the majority of patients who have had all of their teeth removed prefer to eat kibble over canned food.

Thanks for reading!

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