Extreme Prevention

I see it everyday: patients with severe periodontal disease who have reached an age where anesthesia becomes an increased concern. These are patients who have either been having routine cleanings at least yearly to ward off the negative effects of periodontal disease or they are patients who should have had yearly cleanings and didn't. As these pets age they become increasingly susceptible to the effects of periodontal disease and will likely either require multiple cleanings per year or multiple extractions per cleaning. This means that we are looking at either an increase in the number of anesthesia events or the duration of anesthesia events when they occur. While this can be done safely and effectively it is not right for every patient and I would say it's not right for most. The other option is of course to do nothing. Most likely the pet is still eating, playing and acting normally. Sure, they have some bad breath and it's not pretty to look at but what's the real problem? 

I see two problems with it.

It hurts and I've adressed the pain topic before: Pain Article

It is an active infection. I've also touched on periodontal disease: Periodontal Disease

So what do we do? Is it better to have your pet endure multiple anesthesia episodes or to allow them to live with active periodontal disease? I'd say we've reached a different point. We've reached the point where it is no longer possible to keep this mouth- and the teeth within it- healthy. We can make the mouth healthy by removing all of the teeth.

I know, your jaw just dropped. ALL of the teeth? All of the teeth. Your pet cat or dog does not need teeth- they do not really guard your house. Guard dog breeds also tend to be breeds that are much more resistant to periodontal disease. Your pet dog or cat does not need to catch and kill its food nor does it need to defend itself from predators. What your pet does need is a mouth that is pain free and not actively infected.

How is my pet going to eat? Better.

I'm not talking about pets that don't have obvious active periodontal disease on physical exam. I am talking about the cat or dog who has had (or should have had) yearly cleanings and still is requiring extractions or is entering an age where anesthesia events are becoming increasingly less attractive options. These pets have infected teeth; eating with infected teeth hurts. Eating with infected teeth also mobilizes bacteria into the blood stream and can lead to systemic infection. Periodontal infections cause metastatic inflammation that exacerbates arthritis, auto-immune diseases and allergic dermatitis. There is no reason to allow this process to continue.

I have four situations in which I would consider full mouth extraction the best possible solution for a pet cat or dog's periodontal disease:

1. Feline stomatitis is an inflammatory condition within the mouth that is really only properly treated by removing all of the tooth material.

2. Patients who have had yearly cleanings but are still requiring extractions at each cleaning and are either entering their golden years or have been left with teeth in a non functional pattern.

3. Patients who are prone to periodontal disease but have recently aquired a condition that puts them at increased risk for anesthesia. Better to have one last big anesthesia even in that case.

4. Patients where I have tried for several years to address the periodontal disease and have been given the chance to make a different in that pet's life. In those cases I am going to push to maximize the good I can do for that pet by removing any chances of it developing periodontal disease ever again.

Here is a case I had just this morning. It was an older dog who has been very prone to periodontal disease. We had removed several teeth at the last visit. She is incredibly stubborn and won't allow brushing at home and at this visit we were going to be left with only 2 viable teeth. The owner and I instead elected complete removal.

Here are the befores:

And the afters.

This dog will never again require another dental treatment nor will she ever again experience the pain associated with periodontal disease.

Oronasal Fistula

Warning: Some of the photos used in this blog may disturb sensitive readers.

A fistula is simply a communication between two areas that would not occur naturally. There can be fisulas that communicate between a dog's anal sacs and the outside world, between a cow's rumen and the outside world and inside a dogs mouth we can have fistulas that communicate between the mouth and the nasal sinus. The mouth and nasal passages are typically separated by a layer of bone and the tissue lining the mouth and nasal passage. When a tooth becomes chronically infected, part of the body's response is to break down the bone surrounding the tooth. Periodontal Disease When the bone is broken down sufficiently a communication occurs between the mouth and nasal sinus. This leads to food material, water and oral bacteria being transferred to the nasal passage from the mouth. This can lead to sinus infections, sinus inflammation and even pneumonia. These need to be repaired surgically. The surgery is difficult and often has to be repeated due to the large defect we are trying to close with a limited amount of tissue.

This was a recent oronasal fistula repair that happened here at Riverside Veterinary Care, the patient was a Dachshund, this breed is prone to oronasal fistulas. In fact this dog had two, both were the upper canine teeth. The most common tooth for an oronasal fistula is the 4th premolar or Carnassial tooth on the upper jaw.

The picture below is after scaling and polishing and was taken during our charting of the mouth. We go around each tooth and obtain gingival sulcal depths to get an idea of how much active periodontal disease we are dealing with in each mouth. In this case there was a large defect on the inside of the canine tooth.

You can't see the defect just looking at the tooth and would have missed it if only the outside of the tooth was charted. Even on the x ray it can be difficult to see that anything is wrong.

If you look closely at the outline of the big tooth on the left and compare it to the second tooth to the right of that tooth, the outline of the canine tooth is much fuzzier and even appears to be eaten away in some spots. Still, looking at the picture of the tooth below you really can't tell that anything is wrong here.

When I insert a red rubber catheter into the spece behind the tooth however, I can get it to travel out the nostril. I would only do something like this while the pet was completely anesthestized and then only to illustrate the fistula.

I have already given this dog an injection of a local anesthetic and have discussed my findings and plans (including the pictures and the red rubber catheter) with the owner. I now make a long curving incsion into the gums to expose the bone around the canine tooth.

I understand you don't look at canine alveolar bone everyday so you'll have to take my word for it when I tell you that this bone is irregular. The tooth was extracted and the infected tissue was removed. This left a large socket that did a lot of bleeding.

I then place a local antibiotic in the socket and close the defect after preparing the flap so that it rests loosely over the socket. Tension will cause these surgery sites to fail every time and because these surgeries require a second procedure almost half the time anyway I like things to go as smoothly as possible the first time. For that reason, I really take my time making sure my flap is perfect the first time. I use absorbable suture as this little Dachshund probably isn't going to want to let me in its mouth again anytime soon!

The patient went home on some pain medication, with an E-collar (the cone of shame) and will be coming back in 10 days for a recheck. I will let you know how everything went then!