Common Cases

Exactly like in human dentistry, it is important to have radiographs (x-rays images) of teeth to be able to make accurate treatment decisions. Even though most practices now have these facilities, it might be wise to refer difficult cases if it is not available. We can help with interpreting radiographs and help to make the correct treatment decisions.

Periodontal disease is divided into the less severe early stage gingivitis, and periodontitis once more attachment (of the tooth to the surrounding tissue) loss had occurred.

To distinguish between gingivitis and periodontitis during a conscious clinical examination is difficult and, in most cases, impossible. The main reason is that clinically evident  gingivitis could be gingivitis only or in fact merely a sign of periodontitis. Probing and especially radiography (x-ray imaging) with the patient under general anaesthesia confirms the situation and is crucial to formulate the an effective treatment plan.

Without ongoing dental home care, even after effective professional cleaning (ultrasonic scaling and possibly polishing) under general anaesthesia, periodontal disease would almost inevitably reoccur. It is important to realise that professional cleaning should therefore only be considered an important part of the treatment of periodontal disease.

Brushing
All dogs will benefit from daily tooth brushing but some individuals effectively remove plaque through normal earring and chewing behaviour. The benefit of brushing might not be that easy to demonstrate in these animals.

Smaller dog breeds and especially toy breeds have been shown to be more susceptable to periodontal disease, and brushing in these animals are very important.

It is important to use animal specific tooth pastes but it is the mechanical action of brushing that removes plaque and the role of the paste is really to make the process more pleasant and thus better tolerated for longer.

Specially designed animal tooth brushes are available and helps to make the procedure more easy for the one handling the brush and, in this way, possibly better. Any human soft or medium-soft tooth brush could achieve the same result. Like in our own case, remember to replace tooth brushes frequently.

A recent study found that brushing once daily is the best with every other day brushing a close second. Brushing once a week did no better than not brushing at all! So ideally, aim to brush daily but a minimum of three times a week for it to make a difference.

Unlike in humans, that aim to remove food remnants from our tooth surfaces (prevent caries or tooth decay), it is handy to remember that brushing before food is not important in dogs and cats. Reward for allowing brushing by having their beloved food could therefore be a great method to consider. A chew or favourite toy after brushing uses the same positive reinforcement method to teach tooth pets to allow brushing.

To brush cats’ teeth is more challenging but with gentle technique, it is possible. To brush cats’ cheek teeth just push the lips and corner of the mouth out of the way to reach them rather than attempting to fit the brush into the mouth, under the cheek.

Normal dry complete diets are brittle and usually crumbles when chewed. Dogs on such dry food would often have premolar and molar teeth with the cusps of crowns cleave any calculus. Plaque remains on the crowns at the gum line (where it really matters). With  specially formulated  dental diets, the kibbles contains fibres that requires the tooth to cut trough them to break the kibble down to be swallowed. Hills T/D and Royal Canin’s Dental Diet are the two brands that have published data to support their claims. This is an effective additional tool in especially smaller dogs and cats. 

Dogs and cats have primarily cutting teeth allowing these animals to cut off chunks of their prey that can be swallowed. Dental chews that allow teeth to penetrate attempt to simulate this action and such chews could be more effective to remove plaque  Not all chews that claim effective plaque control is effective though. The Veterinary Oral Health Council (VOHC) is an independent organisation of academics and leading veterinary dental specialist. They evaluate such efficacy claims and reward products that have successfully proven its claims, the VOHC seal. The VOHC website describes the testing process and list products that have been awarded this seal. This is therefore a good reference site to evaluate manufacturers' claims: Remain very sceptical of efficacy claims unsubstantiated in this way.

If any snake oil added to drinking water of food was as effective as some claims, we would all add it to our breakfast cereal because periodontal disease is very much a human problem too!

Periodontal surgery
Periodontal surgery is a surgical treatment option that is available to save strategically important teeth, affected by periodontitis. To consider this treatment, oral hygiene and dental home care should be of a very high standard. The primary aim of periodontal surgery is to reduce or ideally eliminate periodontal pockets (bone destruction associated with periodontitis).

Some of the treatment options to consider would be open debridement, with or without bone grafting. Teeth that are suitable for this treatment would be considered on a case-by-case basis. This advanced treatment should really only be considered in specially selected cases with owners able to provide very effective oral hygiene.

To fracture the crown of a tooth by biting down on something hard depends on the force exerted, the angle at which this force is applied and the hardness of the material bitten down on.

Dogs have very strong muscles to close their jaws and is able to exert sufficient force to potentially fracture their tooth crowns. The angle at which the tooth contact the chew is quite random so the only component of this that we as owners can control is the hardness of the chews we provide. To advise safe toys depends on individuals but two considerations might help with the choice.

• If you can make a mark on the chew with your thumb, it is probably safe for your dog to chew on ("rule of thumb")
• If you can bend it, your dog can probably safely chew it safely

Hard nylon chews and some raw hide chews might therefore not be advisable. Deer antlers are rock hard, smelly bones that were used as stone age digging tools and is not suitable dog chews.

Crown fractures can affect enamel only, enamel and dentin, and enamel, dentin and pulp. Exposed dent would be uncomfortable for at least a while and should for this reason be treated s soon as possible.

Discoloured teeth
Tooth crowns could be discoloured by surface staining or by staining from inside the root canal (intrinsic staining). The latter is usually caused by trauma to the tooth that causes bleeding into the root canal. Breakdown products from red bloods cell content, defuses into the porous dentin and this causes the discolouration. A published study indicated that more than 90% of these teeth have devitalised pulps.  

Radiography of these teeth is therefore always indicated. If there are radiographic evidence of devitalised pulp the treatment options are the same as it is for pulp exposure: Either extraction or root canal treatment. Radiographic monitoring should continue if radiography is inconclusive.

Difficult extractions
Extracting teeth of dogs and cats is more difficult than in humans because of many different reasons. The main difference is the different functions of our and their teeth; ours are mainly for grange and crushing food and theirs primarily for cutting off chunks to swallow. The teeth of these predators had been designed to be firmly anchored in the bone of the jaw and in general, the roots of their teeth have relatively long roots in relation to the crown.

Some teeth of dogs are very large and especially with ongoing periodontitis (inflammation that progressively destroy the bone of the jaw), the risk of jaw fracture remains when extracting these teeth.

Some patients require full mouth or partial mouth extractions to treat chronic problems in the mouth. Extracting large numbers of teeth or very large teeth (especially without radiography) are significant and invasive surgery and therefore, such cases are occasionally referred to a specialist.

Cats have a high incidence of tooth resorption and making decisions on extraction of these teeth relies completely on x-ray imaging. Without radiography, it is therefore impossible to decide the best approach when extracting cats’ teeth.

Endodontic treatment
Indicates treatment of the pulp canal system and the pulp (the living tissue with in this canal). The treatment is either vital pulp treatment or root canal treatment. The aim of the former is to maintain the viability of the fragile pulp tissue by applying of dressing material onto exposed pulp. This usually requires removal of some pulp tissue (partial pulpectomy) before the access site is sealed. To monitor the successor vital pulp treatment, frequent radiographic follow-up to imperative. If vital pulp treatment fails (and the pulp dies), the only treatment options that remain for teeth damaged in this way would be either root canal treatment or extraction.

If the pulp of a tooth is exposed to the oral environment, it rapidly becomes infected by the multiple bacteria present. This infection and the inflammation that it triggers would eventually cause pulp death. The only treatment options to consider for these teeth would be either extraction or root canal treatment. During root canal treatment, the tooth is saved by removal of the dead or dying pulp or remnants of it, shaping and disinfecting the root canal and then filling out with the material that would prevent leakage of tissue fluid into the canal. The access site(s) are then restored, either using composite material or by applying a prosthetic crown over the remaining crown and access restorations.

Fracture of the upper and lower jaw of dogs and cats can be repaired in very many different ways. A good method that we often use is interdental wiring and intraoral splinting. Teeth are wired together to reduce the fracture and establish normal occlusion. This wire splint and the teeth are then covered with composite material to create a rigid stabilisation of most jaw fractures.

Intraoral sprints are also very well tolerated by patients. Intraoral splints are far less invasive procedures than plates and screws or external fixators. Tooth roots occupy significant space in the bone of both jaws and therefore placement of screws and pins through the bones of the jaw can therefore easily damaged tooth roots.

Neoplasia (either benign or malignant tumours) within the oral cavity is often diagnosed quite late in the development of the problem. It is impossible to distinguish whether tumours are benign or malignant or merely inflammatory change. Biopsy should be strongly recommended for any mass or lump with in the oral cavity.

Surgical excision of tumours to include healthy tissue margins is frequently the first procedure in the treatment of all tumours. Early diagnosis and treatment is therefore very important and potentially life-saving.

Symptoms of rhinitis (inflammation of tissue within and nasal cavity) include sneezing and nasal discharge.

If one considers the anatomy of the upper jaw, it is clear that the roots of some of the teeth in the upper jaw is very closely associated with the nasal cavity. It is therefore important to consider dental problems as a significant potential because of this condition.

To repair severe trauma of the head and face, it is crucial and often the starting point of the procedure. To establish normal occlusion repair of these fractures has become easier with the use of 3D printed metal implants and procedures that we have successfully performed.

An oronasal  fistula is the communication between the nasal cavity and oral cavity. Acquired oronasal fistulae are often associated with periodontitis at teeth in the upper jaw especially the upper canine or the premolar teeth and could remain ofter extraction of the affected teeth. Congenital oronasal fistulae is usually associated with clefts palates and clefts lips.

The best opportunity to repair these soft tissue defects is during the first attempt. Surgery after failed attempts becomes more challenging because of the compromised blood supply to the soft tissue to be used for these repairs.

Normal occlusion (interlock of opposing dental arcades when closing the mouth) can be altered by either changes in jaw lengths or individual teeth in an abnormal position. 

Treatment of these conditions should be considered if abnormally positioned teeth, either be deciduous or permanent teeth, make contact with other teeth or with soft tissue of the jaw’s. Teeth impinging on soft tissue should be considered potentially painful whether these patients are able to communicate that effectively or not Destruction of soft tissue and bone by this pressure is painful, but very often foreign material is rammed into the soft tissue craters. This causes localised infection and inflammation, causing more pain  .

The basic treatment options available would be:

• Extraction of the teeth causing the painful injury
• Extraction of teeth preventing normal closure of the mouth
• Crown amputation or reduction
• Orthodontic treatment 

Crown reduction to prevent abnormal contact does involve cutting through the pulp within the pulp chamber (the continuation of the rot canal into the crown of the tooth ). To prevent pulp death, pulp exposed during this procedure requires vital pulp treatment. If the latter is performed under surgical conditions, the risks are significantly reduced. Because of the fact that our patients have difficulty to effectively communicate dental pain, frequent radiographic monitoring of pulp vitality is essential. Without a commitment to this follow-up, this procedure should really not be considered as an option. If the pulp damage causes irreversible inflammation and pulp death, the only treatment options for these teeth would be either extraction or root canal treatment.

Orthodontic treatment uses light force to move teeth into comfortable positions. In some cases, ball therapy (chewing on a firm rubber ball) could be sufficient to move upright lower canines into new positions. Orthodontic devises (“braces”) are generally far less involved than in humans and the desired effect is usually achieved within weeks rather than years. Active orthodontic device uses elastic chains or springs to create force in the desired direction. A passive device alters the tooth position by the forced applied during normal closure of the mouth and temporary crown extension is a good example of such devices.

Early diagnosis and referral for assessment and treatment is very important in these cases.

The crowns of teeth could be damaged in many ways including trauma, developmental problems and caries (cavities). Dentin that is exposed by any of these means could be painful or at least sensitive and treatment at the earliest possible opportunity is important. 

Defects could be restored by means of composite material or prosthetic crowns. Caries is a far more common problem in humans than in dogs because of the different shapes of our teeth. Dogs have very few teeth with flat occlusal surfaces that allows the accumulation of sugary foods. Sugary remnants on the crown surface form acids that  demineralised the hard tissues of the tooth. Enamel is very highly mineralised and erosion of this tissue takes much longer; the destruction process continues very rapidly in less mineralised dentin. Exposed dentin would be painful and this pain will increase if the decay process progress closer to the pulp canal. The pulp could eventually be exposed with infection of the pulp and eventually pulp death. Detecting these lesions early (before the pulp is involved) is ideal and these defects can be restored effectively and the affected teeth saved. 

Once the pulp is revitalised, two treatment options to consider would be either extraction or root canal treatment.

Ulceration is a frequent consequence of inflammation of the soft tissue of the oral cavity. Even small ulcers should be considered very painful. The first treatment for affected animals is therefore pain control. All attempts should be made to establish the underlying cause and ideally eliminate that.

Plaque is often involved in the disease process and effective control is often a fundamental component of treatment of such conditions. If alternative methods are not effective, extraction of either some or all of the teeth could be considered. Extraction of these teeth of either dogs or cats very often successfully reduce the plaque burden sufficiently to allow the body's immune system to prevent ulceration. It is very important to remove all root fragments and to confirm this with post extraction radiographs.

With owners providing readily accessible food, dogs and cats will thrive with no teeth at all!

The popularity of pets other than dogs and cats continues to grow.

Especially rabbits and rodents have unique dentition and dental problems are very common problems in these animals.

We offer advanced dentistry services (e.g. radiography extractions and apicoectomy) to these animals too.