Dr. Niemiec’s Pet Dental Cases


A Non-Anesthetic Dentistry (NAD) Nightmare

As you know, veterinary dentists are strongly against the practice of anesthesia free dentistry or Non-Anesthetic Dentistry (NAD). There are numerous reasons for this, but mostly because it is a completely ineffective method of pet dental care. Moreover, the single most important step of a prophylaxis (subgingival scaling) cannot be performed without general anesthesia. Patients are often seen following NAD with clean crowns (visible portion of the tooth), but with significant areas of subgingival calculus. This may be the most damaging issue with this service, as it gives the client a false sense that they are improving the dental health of their pet. Dr. Niemiec along with his colleagues regularly have to have hard discussions with clients who are very upset when dental disease is diagnosed despite “clean” crowns. These clients feel that they have “failed” their pet, allowing them to progress to disease despite their well-intentioned efforts.

The following case contains detailed case photographs and video demonstrating the severity of the circumstances and evidence as to the risks of anesthesia free dental cleanings.

This patient had received regular (every other month) NAD. Despite this, she had waxing and waning halitosis. She was eventually referred to Veterinary Dental Specialties and Oral Surgery for a fractured tooth. Upon oral exam, the fractured left maxillary fourth premolar (208) was confirmed; however the teeth were fairly clean, with a few areas of calculus and gingival recession. (Figures 1-3) The patient was placed under anesthesia and oral exam revealed further areas of recession as well as a draining tract over the left maxillary canine (204). (Figure 4).

Periodontal probing revealed numerous periodontal pockets including a very deep pocket on the left canine (Figures 5-8) ad furcation 3 exposure on several teeth (Figure 9). In addition to the advanced periodontal disease, the patient also had tooth resorption, which is a very painful condition.

Finally, watch to see the right maxillary M1 (109) mobile level 3.

Dental radiographs confirmed severe periodontal loss and TRs (Figures 10-14) and surgically 204 had significant bone loss (Figure 15).

The patient was treated with numerus extractions. When the patient returned for the two week recheck, the owner commented that not only was their pet’s breath  greatly improved, but also had far more energy.

All veterinary dentists have cases similar to this in which pets have suffered needlessly due to lack of proper care. NAD only serves to hide periodontal disease as well as other painful and infectious conditions.

We encourage veterinarians to refer their clients to this article as well avdc.org/afd for more education about the risks of anesthesia free dental cleanings and to encourage regular veterinary dental cleanings under anesthesia as part of their pet’s regular care.

Veterinary Dental radiographs revealed severe bone loss

Treating Severely Infected Pet Teeth with Root Canal Therapy

Veterinary Dental radiographs revealed severe bone loss

Dental radiographs revealed severe bone loss.

Last year, a 10 year old Shih Tsu was referred to Veterinary Dental Specialties and Oral Surgery for a suspect mandibular fracture. This was based on the dental radiographs taken at the referring veterinarian. The patient was placed under general anesthesia and a complete oral exam and radiographs were performed. This revealed very slight laxity at the mandibular right first molar. However the jaw was overall stable. Continue reading “Treating Severely Infected Pet Teeth with Root Canal Therapy” »

Root Canals Enable Bobcat to Keep Vital Teeth

reggiemain_300Reggie was brought to Veterinary Dental Specialties & Oral Surgery in California for evaluation of a recurrent left facial swelling with abscess formation. Reggie is a bobcat who is cared for by Fund For Animals Wildlife Center, who had been keeping an eye on the condition had persisted for about two years. In the past, the swelling responded to antibiotic administration, however it after the condition continued to persist, it was clear that Reggie needed a more thorough veterinary specialist evaluation.

Bobcat Root Canal - Veterinary DentistryAfter being safely anesthetized, a thorough evaluation and veterinary dental x-rays, revealed that three of his canine teeth had exposed pulp secondary to dental attrition (wear). The pulp exposure allowed bacteria from the mouth to infect the endodontic system of Reggie’s teeth. Once the pulp is infected and it becomes necrotic there is no way for the animal’s immune system to combat this infection, which leads to the constant release of bacteria from the bottom of the tooth’s root. The constant release of bacteria leads to abscess formation causing Reggie’s recurrent facial swelling.

The priority for veterinary dentists is always to save an animal’s teeth when possible. In wildlife cases, even those at animal sanctuaries, the animal often relies on heavily on certain teeth, in Reggie’s case the canines. Each of the three infected teeth were treated with root canal therapy, which in typically will last through the rest of the animal’s life.

Reggie is now in far less pain and with a healthy mouth that will allow him to roam and enjoy life at the sanctuary.

Treating Labrador Retriever’s Oral Tumor

Note the obvious swelling of the right maxilla. The owner reported rapid growth of the mass, debulked 2 months prior.

Note the obvious swelling of the right
maxilla. The owner reported rapid growth of the mass, debulked two months prior.

“Mr. Gibbs” is a 12 year old Labrador Retriever who came to Gulf South Veterinary Dentistry & Oral Surgery to have a tumor removed from his mouth.

The large tumor had grown back quickly after his regular veterinarian biopsied it a couple of months earlier. We knew it was a tumor called a plasmacytoma, which is generally not metastatic (does not spread to other parts of the body), but can be locally invasive. The mass was irritating the dog and the owners so we removed it, along with several teeth and part of the upper jaw, or maxilla.

While we were unable to remove the deepest parts of the tumor that had grown into the bones of his nose, “Mr. Gibbs” is much happier and more comfortable than he was before the surgery. He is now seeing a veterinary oncologist (cancer specialist) for follow up treatment of a more serious mass on his skin that we removed at the same time as the jaw surgery.

tumor in dog's mouth

A photo of the tumor in “Mr. Gibbs” mouth.

The incision site at the two week recheck. Everything looks great!

The incision site at the two week recheck. Everything looks great!

 

 

 

 

 

 

 

 

 

There is no sign that either cancer has spread and “Gibbs” continues to do great at home.

“Mr. Gibbs” and his owner were both very happy at the 2 week recheck. One can hardly tell he had a large piece of his upper jaw removed!

“Mr. Gibbs” and his owner were both very happy at the 2 week recheck. One can hardly tell he had a large piece of his upper jaw removed!

If at any point you notice a growth or tumor in your dog or cat’s mouth, or unusual swelling on their face, it’s extremely important to have it immediately evaluated by a veterinary dentist who can determine whether the tumor is benign or malignant and then provide the best possible treatment plan.

 

 

 

 

 

 

 

 

 

 

Miley: A cautionary tale of a Chihuahua with a broken jaw

Miley, Chihuahua with jaw fractureMiley, a three year-old Chihuahua came to Southern California Veterinary Dental Specialties and Oral Surgery for bilateral mandibular (lower jaws) fractures.  Her owners reported that Miley had been found roaming the neighborhood until she was rescued only a few weeks before the fractures occurred.  Prior to the fractures, they noticed moderate to severe halitosis (bad breath), but noted that Miley had been eating and drinking well and had otherwise been doing great.

Miley’s owners were not present when the fractures occurred, so they did not see a traumatic incident.  When the fractures were first noticed, her owners noted that she was acutely painful, unable to fully close her mouth, and could not eat hard kibble.

Pathologic Pet Jaw Fractures:

Chihuahua Jaw Fracture X-Ray Vet DentistryUnfortunately, this story is all too common.  Miley had pathologic fractures of both her left and right mandibles.  A pathologic fracture occurs when the bone is weakened by another disease process making it easier to fracture.  In fact, in our experience the majority of mandibular fractures in small and toy breed dogs are pathologic fractures secondary to severe periodontal disease.  These fractures occur with very mild force from everyday activities such as: playing with a toy, playing with another pet, and even eating.  This was likely true in Miley’s case as her fracture was secondary to bone loss from severe periodontal disease.

The inciting causes of pathologic mandibular fractures are periodontal disease, cancer, and/or osteomyelitis (severe infection of the bone).  In Miley’s case, she had severe periodontal disease of her mandibular teeth.  Halitosis, a sign of periodontal disease, was the owners’ only strong clue that there was disease until the fractures occurred.

Pet Periodontal Disease:

In addition to the fractures, Miley had several teeth extracted due to severe periodontal disease.  Periodontal disease is the number one disease in both adult dogs and cats.  Yet it is often underdiagnosed.  Periodontal disease occurs as oral bacteria under the gums creates pockets surrounding a tooth.  If this bacteria is not kept in check with regular homecare such as brushing and using oral rinses, these pockets will work down along a tooth root causing bone loss.  This type of bone loss led to weakened areas in Miley’s mandibles.  The weakened areas of bone allow everyday activities to cause a pathological fracture.  This is most evident in small breed dogs (under 25 pounds) where the mandible is small and little bone loss is needed before a pathologic fracture can occur.

Pet Jaw Fracture Repair:

There are several methods of mandibular fracture repair.  Based on the nature of the fracture, the pet’s size, and the integrity of the remaining bone following fracture, a board-certified veterinary dentist can determine the best method of repair. Miley’s fracture was immobilized with a special muzzle to minimize the use of her jaw.  The muzzle prevents stress on the mandibles while they continue to heal.

Treatment options vary for periodontal disease based off of the type of tooth, severity of disease, and the purpose of the pet.  A board-certified veterinary dentist can present these options and help you to decide what is best for your pet.  Veterinary dentists work closely with our referring colleagues and provide detailed records and any follow up care recommendations.

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.

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.

Veterinary Dentistry – Sharing Our Knowledge

kressin_globe

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.

niemiec_globe

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.

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.”