Jim Berry: [00:00:00] Welcome to the WSAVA Podcast. Today's discussion explores dental care at both ends of a patient's life, from early intervention to managing age related change. As you listen, consider this. How does age influence your approach to dental decision making? Our interviewer, Cedric Tutt speaks first with John Lewis and later with Heidi Loprise.

Let's listen in.

Cedric Tutt: I have a puppy that has a deciduous fracture and is it necessary to actually extract this tooth? 

John Lewis: Yeah, there's a number of reasons why you would want to have that tooth extracted. The puppy probably won't show any signs of discomfort, but there is likely a decent amount of discomfort associated with exposure of the pulp of a deciduous tooth, just like an adult tooth.
So pain is one reason, and infection is another important reason. We have all seen [00:01:00] those draining tracks that have arisen from that long root of the deciduous canine tooth, where infection travels up through the endodonic system and then breaks out through the mucosa, and that is one issue with infection associated with that tooth.

That can also affect the maturation of the adult teeth underneath the gum line. I've seen a few cases of dogs that have had tetanus with no other wounds or no other history of any surgeries, and it seemed like the most likely origin was a fractured deciduous tooth. In a couple of cases, we've extracted those teeth and found granulomas on the end of the tooth, and we've cultured those teeth and submitted them for histopathology.

And although our culture did not grow anything, we did have histopathology that showed Clostridium like organisms in that granuloma. And then I know Cedric, you had a case, I believe that you [00:02:00] actually did culture clostridium from a granuloma on a fractured deciduous tooth in a dog with tetanus. Is that correct?

Cedric Tutt: Absolutely, yes. 

John Lewis: Yeah. So that's something that's important for general practitioners to keep in mind when they do have a patient that comes in with tetanus that, check out those deciduous teeth, particularly the canine teeth since they're so tall and sharp, they're easily broken. And that can result in an avenue for Clostridium to get into the body.

And these dogs present with the classic risus sardonicus signs, which can progress fairly quickly. So that's one of those rare instances where it would be an emergency to do a deciduous tooth extraction. 

Cedric Tutt: Yeah, thanks very much for reminding us of that because it's not something we would think of immediately.

If we have a dog that has tetanus or tetanus signs normally we're going to be looking for wounds. That's weird, but reminding us that the deciduous dentition could be the root of entry is very beneficial. When we [00:03:00] think about deciduous teeth, there are a few things that can be done. Can you tell us about your approach to persistent deciduous teeth, please?

John Lewis: Yes. I think that there's a lot of good tools and instruments out there to help with deciduous teeth and I, when I teach general practitioners about extractions, I always tell them that deciduous teeth are some of the hardest teeth to remove in their entirety because they're so long and thin and they're easily breakable.

They're almost like an eggshell and so it's important to have some good tools to be able to perform deciduous tooth extractions, and depending on the reason for extracting them, if it's a persistent tooth, at least the adult tooth in that area has erupted. So you can have a good feel as to where that adult tooth is to avoid any trauma to the adult tooth.

But still have to remember that adult tooth root is very close to the deciduous tooth root, and we want to avoid any damage to that forming [00:04:00] adult tooth root underneath the gum line. So I will often do a flap, either with a single releasing incision or a two releasing incision, a pedicle flap to raise up the gingiva and the mucosa to be able to get a nice window created directly over the root of the deciduous tooth, and then gently pry that root out of the window that I create on the lateral surface.

Sometimes I find that luxators are really helpful in those cases, a nice thin luxator blade will help to break down those periodontal ligament attachments without any trauma to the adjacent structures. Sometimes I'll use a piezo surgical unit, and sometimes I'll use a vet tome, which is almost like a little miniature jackhammer that has these thin blades that will get into that periodontal ligament space and work its way down along the periodontal ligament space. So there's a lot of good tools out there to, to make it easier to get those persistent deciduous teeth out. 

Cedric Tutt: Great. Yeah, I think that what you mentioned there about being [00:05:00] careful in removing bone is essential because sometimes when people maybe don't have the, let's say, routine skill to do it and don't take radiographs and don't see the proximity with the developing secondary tooth, we can have damage to the secondary tooth, which then is something that is unsightly, first of all, and secondly, it can be so severe that the pulp of the secondary tooth is exposed because of an enamel defect. 

John Lewis: Absolutely. Yep. And especially in those cases where you're extracting a deciduous tooth in a young puppy to relieve a unfavourable dental interlock, then the adult teeth are not erupted yet.

So it's harder to know exactly where they are and how to avoid them. So those are ones that we often will routinely get referred to us just to avoid trauma to the forming enamel and the root of the adult tooth. 

Cedric Tutt: Yeah. Great. Thank you. Moving on to a bit about malocclusions. If we classify malocclusions as dental malocclusions and skeletal malocclusions, can you [00:06:00] tell us your approach to determining if it is a, a dental or skeletal?

John Lewis: Absolutely. I guess the times when it's important to determine if it's a dental malocclusion versus a skeletal malocclusion is particularly when the mandibular canines are impinging on the soft tissue of the hard palate and there was a, a paper that came out in 1999 by Leen Verhaert, which talked about ball therapy or Kong therapy for treatment of mild malocclusions, where the mandibular canines were not in the proper position.

And when that paper came out, I distinctly remember reading it and saying I, I can't imagine that this is going to work, but then I tried it on my patients and it's impressive how well it works with the caveat that it needs to be a mild malocclusion and hopefully is just a dental malocclusion.

Occasionally, if it's a mild skeletal malocclusion where the mandible is shorter than the maxilla, it might work as well. But if there's a significant [00:07:00] shortening of the mandible or what we would call a mandibular distal occlusion, that is something that's asking too much of ball or Kong therapy. A dental malocclusion is often referred to as a class one malocclusion, where there might be a single tooth or maybe two teeth that are in the wrong spot, but skeletal malocclusion would mean that either the lower jaw is too short compared to the upper jaw, or the lower jaw is too long compared to the upper jaw. And in those cases we sometimes have to use something more significant than just trying something like ball therapy.

Cedric Tutt: It appears that using a ball or a Kong in dogs with malocclusions as described by Dr Verhaert, that the ball or the Kong actually works as an orthodontic device in that when the dog bites on the ball, it helps to move the teeth not only forwards in a mesial direction, but also in a buccal direction. 

John Lewis: [00:08:00] Yeah, it seems we've seen some cases where we've seen some movement in both directions rather than just one and so that can be helpful for mild class two malocclusions as well.

But if it's a significant mandibular distoclusion then other options might be necessary, such as an incline plane, which was a composite material that we would place to create a sliding board for the tooth to work its way down over time, as the dog passively closed its mouth, it would put some pressure on the incline plane and direct that canine tooth to move into a better position.

And lately we've been doing a lot of composite extensions. There was a paper that came out by Dr Sig Storli and that was a real groundbreaking one in the fact that the composite extensions which are placed on the mandibular canines can act as a fulcrum to allow those teeth to move into the proper diastema [00:09:00] as well.

So those are options for either if there's a significant malocclusion to the point where the mandible is so short that you can direct those mandibular canine teeth caudal to the maxillary canines, or if it's a moderate malocclusion where you can direct those mandibular canine teeth rostrally and laterally to the normal diastema.

The challenge, I think, is when there's a moderate degree of mandibular distoclusion where the mandibular canines are directly medial to the maxillary canines. It's very difficult to get those teeth to move to either in front of or behind the maxillary canine teeth and in, in some of those cases as well as in cases where owners are hoping to avoid the potential complications that may occur with orthodontics such as loss of an appliance or having to adjust an appliance with an another [00:10:00] anaesthetic visit, sometimes owners will opt to have crown reduction and vital pulp therapy done on these mandibular canine teeth.

Where we can, under sterile conditions, lower the height of these canine teeth to the point where we will be into the pulp of the tooth. So we will use sterile instruments, sterile irrigation, and have that pulp exposed for a very brief period of time. So once we lower the tooth to the height that we feel would be less traumatic.

We remove some pulp, so we do a partial pulpectomy, and then we can place some medicine on the surface of the pulp. Usually these days we would use MTA, mineral trioxide aggregate, or in the past we would use calcium hydroxide for something like that, and then place a multiple layers of a restorative material such as glass ionomer and composite to seal off that pulp and hopefully minimise the chances of any bacteria getting down [00:11:00] into that pulp and allowing the tooth to continue to mature normally.

So we do a lot of that for owners who are not interested in doing multiple anaesthesias associated with some type of orthodontic movement. 

Cedric Tutt: I guess then for clients that don't want repeated anaesthesias, extraction of the teeth is also an option, right? 

John Lewis: I think that of the three options being orthodontic movement versus crown reduction versus extraction, I would say the extraction is probably the least desirable of the three options if the owners can avoid that, because of how much surface area the canine teeth make of the rostral mandible. If you end up having to extract both mandibular canines, then there is some functional loss associated with that and just like when we lose teeth, the alveolar bone margin will recede. That's true in dogs, so they end up with a very narrow pointed mandible.
It's less functional as that bone recedes. 

Cedric Tutt: Okay, [00:12:00] great. I'm thinking about using a ball or a Kong. What I often find beneficial is to determine the size of the, let's say, toy that we want to use. I might take a ruler and put, I don't know if in America it's called Tic-tac or Blu Tack or something similar, something that we would use to stick a picture on the wall and put that on the ruler, and then press that against the tips of the crowns of the teeth and we have an exact measurement between the teeth and that then can be used as a guide as to the diameter of the ball that we get to use or the diameter of the Kong. 

John Lewis: That's a great idea. I haven't tried that, but I'll look forward to guiding what size Kong to use based on that. 

Cedric Tutt: Sure. John, moving on a little bit, but staying with maloccluding teeth, we have a situation where puppies lower canines are actually biting into the palate.

Now we know that puppies sleep most of the day and when these teeth are embedded in the soft tissues of the palate, it doesn't stop the [00:13:00] jaw growing. Yes, it, of course, it affects the growth of the jaw itself, but we find that the ventral mandible becomes bowed as a result of jaw growth, but the teeth are stuck into the palate.

Is it possible to do orthodontics on these puppies deciduous canines at this point? Or are there other treatments that would be more beneficial? 

John Lewis: Yeah, that's a good question. I think that I personally haven't done a lot of orthodontic on deciduous teeth, but I think that in general, if I do see that unfavourable dental interlock, I do often recommend to owners to consider having those mandibular deciduous canine teeth extracted sooner rather than later to try and allow that mandible to have every opportunity to catch up in growth to the maxilla. It doesn't always happen though, it seems like even when you're pretty early with your extraction of those mandibular canine teeth [00:14:00] that the jaw doesn't always catch up to the length of the maxilla, and you're right there back at square one when the mandibular adult canines erupt.

It depends a little bit on the age of the patient because we know those teeth are in the process of resorbing and we only have a limited amount of time to be able to use those teeth as a fulcrum to try and get those deciduous teeth to a better spot, but, and then the hope is that the adult tooth will follow that same path when the time comes. But, but I think that we have had a few cases where we've done composite extensions on puppies, either due to a malocclusion or due to a case where we had a mandibular fracture and we wanted to do something like a tape muzzle, a conservative treatment but the deciduous teeth weren't tall enough to be able to allow the dog to get its tongue out and lap up food if we maintain the occlusion.

And so lengthening those mandibular canine teeth with some composite might help to allow maintenance of [00:15:00] the occlusion and still allow the patient to get its tongue out to lap up food and water while the muzzle is in place. 

Cedric Tutt: That's fascinating. Yeah. One often thinks that teeth, because they are so fragile that they might not tolerate temporary crown extension, but it's good to hear that it is possible to do that.

Jim Berry: After John Lewis, Cedric Tutt is joined by Heidi Loprise for the second part of this episode.

Cedric Tutt: Hello, Dr. Heidi. I have a few questions that I'd like you to answer for us. Please. First of all. One of the people has said, I have two cats, 10 years old. Both of them were sisters from the same little, the one cat needed all her teeth extracted, and the other cat still has all of her teeth.
Why is this and is it common? 

Heidi Loprise: I've always thought that cats invent ways to get rid of teeth to begin with, and the fact that they're from another planet explains a lot [00:16:00] anyway. But even in the same environment, with the same diet, even maybe the same amount of home care, which may be wiping teeth or brushing teeth for cats which usually doesn't happen. It still comes down to that individual's response to whatever they're presented with. So bacteria in the mouth forms plaque and then that hardens to form tartar, and then we can get periodontal disease and this can cause bone loss and the need for extracting teeth. We can also see something called stomatitis in cats where it's, sure they've been exposed to different bacteria and viruses, even fungi, but it's the immune system of the cat that overreacts and causes severe inflammation. So that's why we can get individual responses, even if they are related. 

Cedric Tutt: Okay, good that you mentioned the different causal organisms. If we just go into that a bit more, there are a few common viruses that we find in cats [00:17:00] that commonly cause respiratory disease. Do they on their own cause dental disease? 

Heidi Loprise: Not just on their own, but we've gotten further studies looking how probably the intracellular presence of calicivirus, which is a upper respiratory for a kitten, but now that we're able to identify it better We think that it may play a part in the stomatitis cats where we do get that extreme immune system, ulcerations, proliferation of tissues, and it can be quite painful for these patients.

So there's different things that can affect them. Even at the beginning, some of the nasal viruses,  calicivirus, herpesviruses can cause ulceration in the mouth as well. So we do have to be aware that all of these can impact our patients, but at the same time, it's sometimes the individual response that makes such a difference.

Cedric Tutt: Right. Thank you. [00:18:00] The next question is from a pet owners who says, my local vet told me that my 16-year-old male newt dog which has a mild mitral valve regurgitation, but is otherwise healthy, might die under anaesthetic. His teeth look really bad and he has a bad breath. What should I do? 

Heidi Loprise: We get approached with this all the time.

We'll either get, oh, my dog has heart disease or kidney disease, or some people have been told that their dog is too old for anaesthesia, for dental cleaning because they do need general anaesthesia, but with good preoperative exams, we do different testing to make sure that the patients are stable enough to go under anaesthesia.

It actually, the benefits of getting rid of that chronic infection, chronic inflammation, can impact the quality of life of these patients, make them feel so much better, so much [00:19:00] healthier. In fact, leaving that dental disease with a dog that has a mild issue with the heart can actually make things worse.

So it's important to get them stable enough for the general anaesthesia. There's always gonna be a risk. Let's just try to minimise those risks and then let's get the mouth taken care of. It is so very important. 

Cedric Tutt: Okay, so what I hear you saying then is that even though the dog is eating well, and sometimes they are obese, it is beneficial to have the dental care done in those animals? 

Heidi Loprise: Absolutely. In fact, so many dogs come in with mouths that you can smell them before you get in the room and they're still eating great. Dogs will eat, cats sometimes won't eat as well, but dogs will eat no matter how bad it is. I just did full mouth extractions on a 54 pound dog a couple weeks ago.

Two weeks [00:20:00] later, he's feeling like another dog. There's no inflammation left in that mouth. Believe me, he smells a whole lot better. And overall, as we look at what, it's not just about the teeth, clean teeth or bad breath. Sometimes even the bacteria in the bloodstream, but more than that, it's that chronic inflammation that can impact the rest of the body.

In fact, I've been doing some senior care research, I guess you'd say, looking up literature, and there's an inflammaging. The presence of inflammation can increase the effects of aging that increase morbidity, which means diseases, and mortality of individuals. So let's get at that inflammation and infection out of the mouth.

Maybe by taking out a lot of teeth, maybe all of the teeth, and that pet will have a better quality of life. 

Cedric Tutt: Thank you. That leads on to the next question which I had. It appears if there are certain breeds, like [00:21:00] for instance, the Poodle, Schnauzer, Miniature Schnauzer and so on that do suffer from very extensive inflammation in the mouth, similar to what we find in cats.

So they have the chronic gingival stomatitis, and what the client wants to know is, if all the teeth are extracted will that resolve the inflammation? And is the inflammation likely to come back if the dog has all the teeth behind the canines extracted? 

Heidi Loprise: So it depends on the individual. This dog that I did a couple weeks ago was really a bad periodontal disease. By extracting the teeth, oh, responded quickly. We get some dogs that will get that ulcerative disease similar to cats and certainly with extractions, those areas tend to heal, be much better, much healthier. But sometimes we'll get some refractory inflammation and sometimes we'll get that refractory inflammation in some stomatitis cats.

So we have to really look at what we can [00:22:00] do, select the ones we need to extract. Sometimes these dogs, especially the little ones, don't like a lot of home care, especially brushing. Dental wipes or even some supplements to help these dogs out. But when it comes to it most times we're looking at extensive extractions.

There are some medical protocols that may help some of these dogs, but yeah, it can be a real challenge and usually the extractions make a big difference. I even know we, we talked about extracting all of the teeth, and I'm sure you've had people ask you, but how will he eat? And they actually eat quite well.

Not many dogs do a lot of chewing. The tongue may hang out a little bit as they're getting used to it. They may be a little bit messy, but they probably start eating better because they feel better. And you know what? One time I had a lady with a Shih Tzu that needed about 18 extractions and she went but [00:23:00] how would he survive in the wild? I know what I wanted to say. I can be a smart alec sometimes, but I turned to her and I went, isn't it good that he has you to take care of him? I said the second thing that came to mind. But yeah, it's, it's amazing sometimes how these little dogs feel, isn't it? 

Cedric Tutt: Yeah, you're absolutely right.

And the fact that a dog can come in that has absolutely no sense of humour because of a pain in the mouth and then we, we see it a week later, all of a sudden it's got a waggy tail and they often tell us that my dogs back to being like a puppy, playing with toys he hasn't played with for years. So that's very encouraging.

Heidi Loprise: I love those little miracles. It just makes my heart warm. But at the same time, I wonder what if we'd been doing good dental care throughout the life of that pet? How much better would that be? You know? Could that expand their lifespan? I think so. I think live longer, I know they [00:24:00] will live better with healthier mouths.

Cedric Tutt: Yes. 

Heidi Loprise: Yeah. 

Cedric Tutt: Great. Okay, so the next question is, I have a friend who had a young dog that had rubber jaw. And I understood that was because of renal disease in the dog, but my dog is 11 years old and he has got rubber jaw. So why is it that my dog has got rubber jaw so late in life? 

Heidi Loprise: It depends on, and it's primarily due to renal disease, although we can see a fairly uncommon parathyroid problem as we look at how the minerals are used and whatnot.

It typically is renal disease, and it could be that it was a younger dog. We had a fairly young dog one time years ago, if you remember Dr. Wiggs, that yeah, it was quite extensive. But even older dogs, again, the prevalence of renal disease can increase and if that isn't treated adequately, then the mineral imbalance, we [00:25:00] call this renal mineral imbalance, can cause that weakening of the jaw, can make it very soft in comparison to what it should be.

Plus add periodontal disease to that, and especially again in these little dogs, it can take out bone on the mandible, the lower jaw, and we have little dogs that haven't been in for a while and they have bad bone loss and then they fall off the bed or a big dog jumps on them and it breaks the jaw because there's already bone loss there.

So we really need to provide good care, especially for these small dogs. 

Cedric Tutt: Great. Okay. And then another one is my cat, who's fairly old and we consider old cats to be 17, 18 years old, needs to have anaesthesia to have some teeth extracted. Doesn't need all the teeth extracted. He needs some extracted, but my vet has told me that the extractions can be particularly [00:26:00] complicated in older cats and therefore the anaesthetic might be extended somewhat.

Can you help me understand why anaesthesia is needed, first of all? Because when I go to the dentist, they give me local blocks, and maybe you can talk about that too, but why anaesthesia is required? And then what precautions we might take or the vet would take to be sure that my animal is going to wake up after the anaesthesia?

Heidi Loprise: So with our older pets at doing any adequate dental procedure, we need general anaesthesia, period. anaesthesia free dental cleaning cannot get the disease underneath the gum line, we cannot take radiographs. With general anaesthesia, we put in an endotracheal tube in the breathing tube, the trachea, to make sure that protect their airways.

We can support them with oxygen. We give them IV catheter fluids. We have warming blankets, special warming devices [00:27:00] and good monitoring, checking heart rate, the EKG respiration rate, how good their oxygen tension is. All of these things, really good care under anaesthesia, especially with the older pets. And as we look at the older pets, we try to use lower amounts of the sedative and anaesthetic products just to affect.

In fact, I like using ones that I can reverse once a procedure is done, so we don't have as much of that drug in their system. You mentioned that humans get the local blocks to help numb the areas. Even though they're under general anaesthesia, we can use the local blocks, the regional blocks, so they're numb, and then we can use less anaesthetic gases and then we can keep them a little bit lighter.

Now, particularly when it comes to older pets, I get a little bit anxious about the amount of time they're under anaesthesia. A good friend of mine who's an anesthesiologist, [00:28:00] Sheila Robertson, mentions that two and a half to two hours is a fairly good range, even if blood pressure and body temperature is still good.

So we let pet owners know that it is absolutely appropriate to consider staging a procedure. We might do the cleaning and maybe some of the simple extractions during that first time, keeping them nice and steady, and especially if it's getting close to that two hour mark. Because when we take our dental x-rays, sometimes we find problems that were hidden.

That's why it's again, so important for that general anaesthesia. There are cases where we may decide to wait another two to four weeks, and then we can do the more complicated oral surgery then, again, to make two shorter anaesthetic procedures. Now, if everything's gonna be done within a two, two and a half or so hour range, then that's great.

But it's good to have options, [00:29:00] especially if we're looking at potentially challenging procedures. 

Cedric Tutt: Great. What I'd like you to do, please, is just to discuss home care. Now home care obviously starts with animal as a puppy or a kitten and goes on to to adult life. So could you just chat a bit about the use of brushes, oral antiseptics, maybe different diets and toys that are helpful in developing a good home care regimen? 

Heidi Loprise: Absolutely. So good home dental care is important for oral health. We know we brush and floss, but still go to the dentist. I think of it like a team sport, so everybody's working together. While it's best to get a kitten or puppy accustomed to it early on, you can still start, you, you can teach an older dog new tricks. It's possible. Brushing will always be the gold standard. Having that soft bristle at a 45 degree angle to the tooth in a circular motion, getting all the [00:30:00] areas, especially as we're looking at periodontal disease, if we're unable to do a regular toothbrush, I'll either have them get dental wipes or maybe a smaller, really soft toothbrush and come from behind the pet, not from in front.

Come from the side or from behind, and use that toothbrush or wipe on the side of the face while you're still scratching their chin or scratching their ear, make it pleasant for them. Then gradually get them used to having you pull back on those lips so you can get that wipe on those teeth and you can get the two surfaces with a wipe or the smaller toothbrush.

Now, in addition, there are things we can add to the water that can help with the bacteria, the breath a little bit, probably as easy as it is, it's not as effective as other methods such as brushing or wipes, but it can be helpful. And then using different dental diets or treats can be helpful as well.

When plaque is soft, that bacteria and food is [00:31:00] soft on the tooth surface, that's when we can brush, we can wipe, or the pet can chew on foods and treats and toys to help remove that soft plaque before it hardens into tartar. So regular care with that can be important. Chew toys that are appropriate. I don't know if you have owners giving antlers for chew toys? We do here in Texas and hard objects such as antlers, bones, even ice can break teeth.

Because they can really chew on them. So we wanna make any kind of chew toy that you can bend or put your thumbnail into and I'll also have owners really watch the pet the first time they're using one of those chews or treats 'cause we don't want them just swallowing it whole. There has to be some chew time involved.

So yeah, there, there's a lot can be done at home to help out. But we'll still need the regular professional care.

Jim Berry: [00:32:00] Thanks for joining us on the WSAVA podcast where we are transforming care one episode at a time. We hope today's discussion was helpful. Wherever you are in the world, you'll find more information and further resources on the topics discussed in the show notes, and we look forward to sharing our next conversation with you very soon.