Fig. 5 - Riley 2 weeks after the surgery.  He is fully recovered and very happy!

Mr. Riley, a Special Dog with a Special Story

Mr Riley is a 13-year-old Labrador Retriever who presented to Southern California Veterinary Dental Specialties and Oral Surgery in November 2013 for a significantly abscessed carnassial tooth.   This is a one of the largest teeth in a dog’s mouth, with 3 roots, and is situated just under the eye on the upper jaw. An abscess indicates deep infection, and is painful as well as leading to many other health problems. Mr. Riley’s tooth root infection was only partially responsive to antibiotics and he was suffering with intermittent chronic pain.

Upon pre-surgical evaluation for oral surgery, a heart murmur was found on Mr. Riley’s physical exam.  Thus, in order to minimize any surgical/anesthetic risk, we recommended that Mr. Riley be evaluated by a veterinary cardiologist prior to anesthesia.  We expected that we would still be planning for dental surgery, as in the vast majority of cases, animal patients with heart murmurs are still good candidates for anesthesia.  However, Mr. Riley was not a typical case.

An image of Mr. Rileys cardiac ultrasound revealing a large heart mass (red arrow).

An image of Mr. Rileys cardiac ultrasound revealing a large heart mass (red arrow).

Mr. Riley was seen by Dr. Joao Orvalho at the UC-Davis (San Diego) cardiology service.  He diagnosed Riley with a large mass/tumor in his heart (Figure 1) , and explained that this would actually create a high risk situation for anesthesia and surgery. This is because if Riley’s blood pressure was to change much in either direction (get too high or too low) the mass/tumor could move into the valve of the heart and  obstruct the blood flow (creating a situation like a heart attack).  Furthermore, this heart mass was expected to give Mr. Riley a very poor prognosis ultimately for long-term survival.  For these reasons, Riley’s owner/pet parent elected not to proceed with surgery for the tooth extraction.  Riley was continued on long term antibiotic therapy which kept the infection at bay.

Intraoral picture of the Riles maxillary fourth premolar with a very small fracture (white arrow) .  This small fracture is enough to create infection, and therefore fractured teeth should be radiographed.

Intraoral picture of the Riles maxillary fourth premolar with a very small fracture (white arrow) . This small fracture is enough to create infection, and therefore fractured teeth should be radiographed.

No direct treatment was available for Mr. Riley’s heart condition.  That is, there was nothing conventional medicine could do to offer Riley any further help or to work toward increasing his lifespan.  However, Riley was already being treated with acupuncture by a local holistic veterinarian for his arthritis issues.  When Dr. Katie Kangas, of the Animal healing Center in San Diego, was informed of Riley’s cardiac condition, she changed his treatment plan to include therapies to address this issue.  Riley’s owner did a great job implementing all of his nutritional supplements and herbal and homeopathic medications, as well as scheduling monthly rechecks with the cardiologist.  Mr. Riley actually continued to do very well overall, with his biggest issue being flare-ups of the infected tooth.

Intraoral dental radiograph of the infected tooth.  This confirms the bone loss from the infected tooth (red arrows).

Intraoral dental radiograph of the infected tooth. This confirms the bone loss from the infected tooth (red arrows).

Seven months after the original diagnosis was made, much to the surprise of Dr. Orvalho, another recheck cardiac ultrasound revealed that Mr. Riley’s heart mass had still not grown or progressed in any way. The only explanation for the lack of progression appeared to be the holistic veterinary care.  However, the tooth infection was now posing the biggest problem, as the antibiotics were no longer working to control Riley’s infection or his level of oral pain.

At tis point, Riley was represented to SCVDS & OS.  Based on the significant anesthesia risk, we brought in a veterinary anesthesiologist, Dr. Amber Hopkins from Veterinary Specialty Hospital, San Diego.  She agreed that Riley’s situation did indeed present more risk, but she felt it was definitely worth proceeding.

Intraoral intraoperative dental picture of the infected tooth.  This confirms the bone loss from the infected tooth (purple arrow).

Intraoral intraoperative dental picture of the infected tooth. This confirms the bone loss from the infected tooth (purple arrow).

Dr. Hopkins anesthetized Riley and Dr. Niemiec performed an evaluation and dental radiographs which confirmed the significantly infected tooth (Figures 2 and 3).  Dr. Niemiec then quickly and completely extracted the affected tooth.  An intraoperative picture (figure 4), reveals the degree of bone destruction by the infection.  Anesthesia and surgery were routine and Riley recovered normally and went home that same night.  There were no problems post-operatively!  At his two-week recheck, the surgical sites in Riley’s mouth were completely healed.  Riley’s owner reported that he was actually much brighter and happier than he had been for a long time, which provided evidence that the infection was bothering him even before the noticeable signs had occurred. (Figure 5)

Riley 2 weeks after the surgery.  He is fully recovered and very happy!

Riley 2 weeks after the surgery. He is fully recovered and very happy!

Mr. Riley’s story is an excellent demonstration as to what can be accomplished when a team of veterinary experts are brought together.  The vast majority of patients can enjoy improved health from proper dental care, and even very “sick” or compromised patients can benefit from life altering dental procedures.

Stick stuck in Dog mouth

Every Rose has its Thorn

Stick stuck in Dog mouthHailey is a beautiful golden retriever who came to Dr. Niemiec of Southern California Veterinary Dental Specialists for bad breath without obvious gum disease.  The only way to accurately assess and diagnose any pet dental condition is under anesthesia and with radiographs.

So, Hailey was placed under anesthesia and initial examination revealed a stick across her palate and wedged between the big chewing teeth on the upper jaw. This was a bit of a surprise and further questioning of the owner revealed that Hailey loved rose bushes and would occasionally chew on them.  Examination of the stick confirmed that it was indeed a piece of a rose bush. Unfortunately the stick had created significant gum and bone damage in the area between the roots of the major chewing teeth.

Veterinary dental radiographs were taken and then the surgical process begaan. Dr. Niemiec removed the stick and then elevated the palate tissue to expose the areas between the roots of these important chewing teeth. After the roots were cleaned, bone grafts were placed in the area to help regrow the lost bone.  She did lose one smaller molar due to the advanced disease, but this will not affect her life.

At two week recheck, she is happier and her breath is much better.  There is now a new fence around the rosebushes!

When you notice something suddenly different, like increased bad breath, it’s very important to find a veterinary dentist to evaluate your pet. You never now what the problem could be.

For veterinarians seeking more information about periodontal surgery, order Dr. Niemiecs text book “Veterinary periodontoliogy” here.  

acrylic splint for pet jaw fracture

Acrylic Splints for Mandibular Fracture Repairs

Brook A. Niemiec, DVM
Diplomate, American Veterinary Dental College
Fellow, Academy of Veterinary Dentistry
Southern California Veterinary Dental Specialties

acrylic splint for pet jaw fracture

Figure 1

Introduction:

Traumatic oral fractures are a fairly common occurrence in veterinary dentistry.  There are numerous options for therapy and the all have advantages and disadvantages as well as indications and contraindications.

Acrylic splints (Figure 1) are the treatment of choice for most veterinary dentists for the vast majority of oral fractures.  The main reasons for its popularity are the fact that it is highly successful and non-invasive.  Since there are no metal implants in the bone, there is no chance of damaging the tooth roots or nerves/blood vessels. (Figure 2)  Further, they provide immediate return to function and is well tolerated by the patient. (Figure 3)   Finally, a second surgery is not necessary for removal.  To remove the splint, the acrylic is cut into pieces and removed from the teeth.   Finally, the teeth are cleaned and a bonded sealant applied to the areas included in the splint. (Figure 4)

KE Apparatus are the fixation of choice among veterinary surgeons.  They are very effective in treating long bone fractures.  They are most valuable in significantly comminuted fractures as they have the ability to easily provide a rigid fixation in a convoluted and complex environment.  In addition, they are a good choice for patients with no teeth. (Figure 5)   However, veterinary dentists rarely if ever make use of this technique.  This is for several reasons.  First, it is very challenging to miss the tooth roots and mandibular canal during placement. (Figure 6)  In addition, the bulkiness of the buttress plate makes the appliance unwieldy. (Figure 7)  There is also a decent chance of infection since the appliance provides a direct pathway for the oral bacteria to the affected bone.  Finally, a somewhat invasive second surgery is necessary for their removal.

Bone plates are rarely used in oral fracture repair as the inflexibility of their screw placement and difficulty in adapting them to the mandible make them a less than ideal choice. (Figure 8)  In addition, a fairly invasive second surgery is necessary for their removal. Therefore, the vast majority of veterinary dentists still prefer the atraumatic acrylic splints for the vast majority of oral fractures.  Mini plates are best used for distal mandibular (behind the teeth) and ramus fractures, as well as edentulous patients where acrylic splints are not an option.  They can be used anywhere, but their significant invasiveness makes them a less than ideal treatment choice.

Conclusion:

There are numerous options for repair of oral fractures.  In general, the least invasive method is best.  However, in pathologic or comminuted fractures, as well as fractures of the ramus, mini plates provide an excellent option.  When possible acrylic splints provide appropriate fixation and are non-invasive, which make them the treatment of choice for the majority of veterinary dentists.  Regardless, veterinarians who are treating oral fractures should be comfortable with a variety of fixation modalities and use the correct one for each presentation.

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Veterinary Dentistry – Sharing Our Knowledge

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Dr. Kressin, DVM, DAVDC

Dr. Dale Kressin of Animal Dentistry and Oral Surgery Specialists and Dr. Niemiec of Southern California Veterinary Dental Specialties have teamed up with Animal Health International to teach weekend dental courses to general practitioners and technicians around the country. Most recently, both veterinary dentists taught a wide range of topics to 50 veterinary professionals at Globe University in Appleton, Wisconsin.

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Dr. Niemiec, DVM, DAVDC

Saturday included a day of lectures. Dr. Kressin’s team taught dental radiology, periodontal therapy and regional anesthesia. Dr. Niemiec presented on oral pathology, periodontal disease and surgery, dental radiology techniques and interpretation, dental extractions, pain management, and increasing veterinary dental compliance.

On Sunday, students participated in a full-day, wetlab, which provided extraordinary hands-on experience with extractions, dental radiology, dental prophylaxis, bonded sealants and nerve blocks.

Read more about the event from Globe University.

safari

Tiny Yorkie, Major Dental Problems

yorkie dental disease

Dr. Niemiec with Safari, a rescued 2lb.  Yorkie rescue with severe dental disease.

Safari, a Yorkie in foster placement with Yorkshire Terrier National Rescue, weighed in at less than two pounds when she presented for veterinary evaluation. Unfortunately, Safari had severe dental disease with very infected teeth and gums.

A referring general practice veterinarian at the Governor Animal Clinic indicated that specialty care with Dr. Niemiec and Southern California Veterinary Specialties would be the right decision for the best success for Safari. Due to her extremely small size, there were concerns regarding anesthesia and also for significant risk of breaking her tiny jaw during the tooth extractions procedure. These risks would be greatly minimized by having a board certified veterinary dental specialist perform her needed dental procedures.

Safari was scheduled for dental surgery with Dr. Niemiec. A complete oral examination and dental  x-rays required general anesthesia, which was performed with safe and current standards of advanced veterinary medicine. The exam and x-rays revealed severe gum disease with infected tooth roots of nearly all the teeth in her mouth. In addition, there were several retained puppy/baby teeth which were also infected. Dr. Niemiec performed extractions of all but Safari’s two lower molar teeth. There were no surgical complications and Safari recovered very well from anesthesia.

Thanks to advanced veterinary dental care, Safari is now much happier and healthier, without a painful mouth; and she is now looking for a forever home. If you are interested in adopting Safari or any other homeless Yorkie dogs, please visit www.yorkierescue.com.

What Safari’s foster provider shared with us:

 

“Your confidence in the surgery required to fix her mouth has given us all hope that Safari will be able to overcome the first of many obstacles she will face in order to live a healthy life. Her teeth are the worst we have ever seen in over fifteen years of Yorkie Rescue, and we knew only the best would feel poised undertaking the surgery required to clean out her severely infected mouth. Your reputation precedes you with good reason.

We are sorry we were unable to thank you in person today, and we want to reiterate our most sincere thanks on behalf of everyone at Yorkshire Terrier National Rescue, and especially Safari herself, for putting her on your surgery schedule.”

Dog with periodontal disease

Hoping to Save Dog’s Incisor Teeth After Anesthesia Free Dental Care

Dog with periodontal diseaseBrioso had been getting anesthesia free dentistry performed for the last few years. Upon a regular veterinary visit, the doctor examined his mouth and teeth, which looked good externally. However, the vet then performed an Orastrip test to help identify periodontal disease.

OraStrip canine periodontal disease test strip

The test results were positive for periodontal disease and the patient was placed under anesthesia for an exam and dental radiographs (x-rays). Unfortunately, numerous severely diseased teeth were found, including the dog’s lower incisors which were very loose.

Brioso was referred to Dr. Niemiec of Southern California Veterinary Specialties to try and save his incisors, as extraction of a dog’s incisors not optimal and when possible, veterinary dentists will make every effort to preserve these teeth.

In order to save the teeth, a periodontal flap was performed to clean the infected root surfaces, followed by bone grafting and a barrier to attempt to regrow the lost bone. In addition, because of the loose teeth, a periodontal splint was placed to help the area heal.

Cases like this are becoming more common as more pet owners are choosing to skip proper veterinary dental care, for anesthesia free dental cleanings. Like other cases, Brioso’s demonstrates the ineffectiveness of anesthesia free pet teeth cleanings and the potential damage and more extensive treatment costs in the long term. While it is good news we have the technology to save pet teeth when possible, veterinary dental professionals would prefer a pet receive proper pet dental cleanings which can prevent pet dental disease from becoming so severe.

Below are images of Brioso’s case, however it will take up to six months to determine if the bone grafting worked and his teeth saved.