Veterinary Dental Articles

Oral Fracture Repair: Wiring and Composite Splint

Orofacial trauma can result from a variety of mishaps, such as motor vehicle accident, fall from a height, kicking injury or bite wounds.  Initial assessment of orofacial injuries should be done gently and preferably under sedation, proceeding from least invasive to most invasive.  Evaluation should focus on asymmetry, swelling, discharge and injuries to adjacent structures.

Oral Fracture Radiograph

Oral Fracture Radiograph

Intraoral radiography is essential for accurate and complete evaluation of oral fractures, especially in relation to the teeth and the intricate bone of the mandibles and the maxilla.  Radiography of the skull and CT scanning may also be valuable for imaging the location and extent of injuries.  Occlusion, tooth mobility, tooth fracture, TMJ function and soft tissue defects/injuries must all be assessed.

The main objectives in the repair of oral fractures are the maintenance of proper occlusion and the return to full function of the jaws.  For this reason and because there are so many sensitive and vital structures in and around the mouth, minimally invasive repair techniques are preferred whenever possible.  Interdental wiring techniques in combination with acrylic or composite splinting represent very effective means of repairing oral fractures.

Oral Fracture Repair Radiograph

Oral Fracture Repair Radiograph

Using the teeth as anchors for rigid intraoral stabilization not only eliminates the need for additional external hardware or large amounts of buried implant material in a contaminated/infected situation, but it also aids in the preservation of proper occlusion.  The anchoring teeth on either side of the fracture line can be wired together to anatomically reduce the fracture fragments and in so doing can reestablish the proper occlusal relationship between the maxilla and the mandible.

The main goal of this wiring is fracture fragment reduction, not to provide the sole stability for bone healing.  Once the interdental wiring is applied and tightened properly, an intraoral splint is applied over the wire.  The wire in this case acts somewhat like rebar in concrete and allows for the combination of the wire and splint material to complement each other synergistically.  Acrylic has been used quite effectively for many years as an intraoral splint material that may be laid down over the wiring to provide the necessary stability for healing.

Self-cure composite is a high-tech alternative to acrylic that is now available.  Unlike the acrylic, composite has no noxious fumes with which to contend.  The composite material can be applied directly to the teeth and attached interdental wiring, bonding securely to each.  The material is smoothly shaped when it has set completely to help prevent serious periodontal insult and soft tissue trauma.  Care is also taken to avoid interference of the occluding teeth with the splint.

The patient is fed a softened diet and is not permitted to have chew toys while the appliance is in the mouth.  The combined wiring and splinting is left in place for about four to six weeks, until a bony union has occurred.  Then the appliance is carefully removed to avoid damage to the teeth or soft tissues of the mouth.  The teeth are thoroughly scaled and polished to eliminate plaque build-up from the healing phase.

Anesthesia Free Dental Cleanings

At ADOS we are more frequently encountering dogs that have had “Anesthesia-Free Dental Cleanings” or what has been termed “Non-professional Dental Scaling” (NPDS).  The alternative is professional dental scaling that require general anesthesia.   There are a few reasons for this notable increase.  This is primarily the result of more owners being aware of the importance of oral health care for their pets.  These owners also have natural concerns about the risks of anesthesia and the associated costs.  Unfortunately, Anesthesia Free Dental Cleaning has been marketed as an attractive alternative that touts the same benefits as professional scaling without the cost and risks.  By definition, a complete and comprehensive oral exam includes a complete visualization of all structures, periodontal probing and dental X-Rays.  In spite of claims some individuals make, it is technically impossible for anyone to perform a “complete, comprehensive and thorough” oral assessment on our companion animal patients without the assistance of general anesthesia.  As a corollary, proper treatment of any oral problem is even less possible to perform in a conscious patient.

Unfortunately, without the benefit of general anesthesia, pets most often do not receive the proper and timely preventative (maintenance) care, diagnosis and treatment of oral problems.  It is acceptable for well meaning clients to decline professional treatment because of their fear of anesthesia or if they cannot afford it, however, it is another thing to be fooled by the marketing of untrained individuals that target this fear and offer an alternative that is “just as good”.   This is a service whose marketing sounds appealing and logical on the surface, however, it promises a lot more than can be delivered.  Non-Anesthetic Dentistry is essentially a cosmetic procedure that addresses only the visible surfaces of only some of the pet’s teeth.  What results are pets that are not receiving thorough preventative care and some have serious dental problems that go undiagnosed and/or are improperly treated.

As previously noted, not all surfaces of a pet’s teeth are even visible in a conscious patient.  The palatal and lingual aspects of the dentition are simply not visible on an awake patient.  Periodontal disease affects surfaces for 360 degrees around the teeth. Even in human patients, most periodontal infections start in locations between teeth where the toothbrush does not reach.  The bacteria that cause periodontal disease are especially biologically active subgingivally (below the gumline).  Subgingival biofilm bacteria and infection (if developed) is not addressed with Non-Anesthetic Dentistry and a false sense of accomplishment is conveyed. These pets continue to be affected for years with chronic oral infection (and associated inflammation) which progresses to the point of potential pain, tissue loss and eventually tooth loss.  When infections are finally recognized, the patients are usually older, often have additional health related problems that increase the risks of anesthesia.  Instead of treatment being an elective procedure on a relatively healthy patient, there is often urgency to treating the problem on a less healthy patient.  The problems become not only more urgent to treat, but treatment costs are then often greater.

Although there is always some degree of inherent risk, most major anesthetic risks are associated with two things: 1) the general health of the patient. (When appropriate preanesthetic health screening have been performed, the risks associated with anesthetic management are markedly lower.  This same holds true for most of our patients with other existing health related problems.  The more we know the details of your pet’s health, the safer we can deliver anesthesia and effective oral health care.)  2) the level of training, knowledge, caring and skills of those individuals administering and monitoring the anesthesia itself. (this of utmost importance for anesthetic safety.  This arena of care is behind the scenes, and is not the same in every veterinary (or human) facility.  It’s what goes on behind the scenes that counts.  ADOS maintains among the highest standards for anesthesia and anesthesia related care.  At ADOS, we are located within The Life Centre campus and we have the benefit of collaborative expertise, knowledge and support of other AVMA board-certified specialists.  This includes cardiology, internal medicine, emergency/critical care, ophthalmology, oncology, and surgery.)  Please refer to the preanesthetic risk assessment page on our website (animaldentalspecialist.com) for information on proper preanesthetic risk assessment and required testing.

In California, a recent (2012) case of a fractured jaw led to a ruling against the party preforming anesthesia “Anesthesia Free Dentistry”.  Subsequent to this ruling, the Board of Veterinary Medicine of the State of New Jersey banned Non-professional Dental Scaling as practicing veterinary medicine without a license. Veterinarians who support individuals involved with “Anesthesia-Free Dentistry” should consider the professional, ethical and potential legal considerations.

The following is the American Veterinary Dental College (AVDC) Position Paper on Companion Animal Dental Scaling Without Anesthesia

In the United States and Canada, only licensed veterinarians can practice veterinary medicine. Veterinary medicine includes veterinary surgery, medicine and dentistry. Anyone providing dental services other than a licensed veterinarian, or a supervised and trained veterinary technician, is practicing veterinary medicine without a license and shall be subject to criminal charges.  Recently (2012, in the state of California) an individual who was performing anesthesia free dental cleanings on pets, was convicted of practicing veterinary medicine without a license.

This position statement addresses dental scaling procedures performed on pets without anesthesia, often by individuals untrained in veterinary dental techniques. Although the term Anesthesia-Free Dentistry has been used in this context, AVDC prefers to use the more accurate term Non-Professional Dental Scaling (NPDS) to describe this combination.

Owners of pets naturally are concerned when anesthesia is required for their pet. However, performing NPDS on an unanesthetized pet is inappropriate for the following reasons:

1. Dental tartar is firmly adhered to the surface of the teeth. Scaling to remove tartar is accomplished using ultrasonic and sonic power scalers, plus hand instruments that must have a sharp working edge to be used effectively. Even slight head movement by the patient could result in injury to the oral tissues of the patient, and the operator may be bitten when the patient reacts.

2. Professional dental scaling includes scaling the surfaces of the teeth both above and below the gingival margin (gum line), followed by dental polishing. The most critical part of a dental scaling procedure is scaling the tooth surfaces that are within the gingival pocket (the subgingival space between the gum and the root), where periodontal disease is active. Because the patient cooperates, dental scaling of human teeth performed by a professional trained in the procedures can be completed successfully without anesthesia. However, access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient. Removal of dental tartar on the visible surfaces of the teeth has little effect on a pet’s health, and provides a false sense of accomplishment. The effect is purely cosmetic.

3. Inhalation anesthesia using a cuffed endotracheal tube provides three important advantages… the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examination and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.

4. A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient. The surfaces of the teeth facing the tongue cannot be examined, and areas of disease and discomfort are likely to be missed.

5. Hand scaling alone (without polishing) can make the tooth surface even more plaque retentive.  The metal scaler is harder than the surface of the tooth and it can microscopically etch the surface. These microetchings create a rougher and larger surface area where plaque bacteria can attach to the tooth.  This actually accelerates plaque (bacteria) and calculus reaccumulation and fuels gingivitis and periodontitis.

Safe use of an anesthetic or sedative in a dog or cat requires evaluation of the general health and size of the patient to determine the appropriate drug and dose, and continual monitoring of the patient. Veterinarians are trained in all of these procedures. Prescribing or administering anesthetic or sedative drugs by a non-veterinarian can be very dangerous, and is illegal. Although anesthesia will never be 100% risk-free, modern anesthetic and patient evaluation techniques used in veterinary hospitals minimize the risks, and millions of dental scaling procedures are safely performed each year in veterinary hospitals.

To minimize the need for professional dental scaling procedures and to maintain optimal oral health, the AVDC recommends daily dental home care from an early age. This should include brushing or use of other effective techniques to retard accumulation of dental plaque, such as dental diets and chew materials. This, combined with periodic examination of the patient by a veterinarian and with dental scaling under anesthesia when indicated, will optimize life-long oral health for dogs and cats.

For general information on performance of dental procedures on veterinary patients, please read the AVDC Position Statement on Veterinary Dental Healthcare Providers, which is available on the AVDC web site (www.AVDC.org). Please feel free to also visit a website put together by the AVDC Public Relations Committee (www.AVDC.org/AFD/) for more helpful information for veterinarians and pet owners. For information on effective oral hygiene products for dogs and cats, visit the Veterinary Oral Health Council web site (www.VOHC.org).

The Importance of Veterinary Dental Radiology

Dental radiology is the core diagnostic modality for veterinary dental care.  Trying to diagnose and treat dental disease without radiographs is like trying to treat ear disease without an otoscope, or diabetes mellitus without blood glucose measurements.

If a practice is not currently taking dental radiographs, they are sending many, if not most, of their patients home with painful dental problems. Unfortunately, the pets seem to act fine, they eat well according to the owners, and rarely do they show any overt sign that they are in pain. Many owners assume that because there is no obvious pain, there is no pathology.  Many veterinarians assume that unless a tooth is loose, it does not require treatment.  Nothing could be further from the truth.  The accompanying dental radiographs all illustrate cases where non-mobile teeth in apparently normal patients are associated with significant pathology.  When these types of problems are found and addressed, the patients typically act “years younger”, according to the owners.  If you start taking dental radiographs and treating the hidden disease in your patients, you will likely find that the majority of your positive client comments are generated from your dental cases.

The cost for implementing dental radiology is minimal.  New dental X-ray machines are available for around $3500. I would recommend avoiding older human dental X-ray units, as there can be issues with inconsistent exposure times and radiation scatter. An additional $300 gets you a chairside developing tank, film, film clips, and chemistry. Most practices will be happiest using D-speed X-ray film, which provides high detail and is more forgiving of errors in exposure and processing. To save time, a small X-ray view box should be located next to the chairside developer. You should be able to pay for your entire dental radiology investment of around $4000 in one month. You will realize income from the dental radiographs, as well as from the treatment of otherwise hidden pathology. What other area of veterinary medicine provides this kind of return?

A more recent advancement in dental radiology is the availability of digital systems, which eliminate the need for film and chemistry. Digital systems typically range from $7000 to $16,000 in cost, and represent the wave of the future for many practices. Images are organized in a database, and must be backed up regularly to prevent loss of patient records. Some digital imaging software allows for the easy importing of high-quality pictures, printing of client letters with radiographs and pictures, and displaying images from the pet on a large screen in the exam room. Owners love seeing pictures and radiographs from their pet!

The idea of dental radiology is a new one for many practitioners and their clients. You will have to invest a few hours of time and staff training to achieve good results, but the rewards in improved patient health, client satisfaction, and practice revenue will be enormous.  I have yet to find one practice, regardless of size, location, or socioeconomic status of their clientele that has failed to successfully implement dental radiology if they tried it.

Fractured Pet Teeth

Fractured teeth are common in dogs and cats and usually caused by either trauma to the head or from pets chewing on inappropriately hard objects such as bones. Often fractured teeth go unnoticed by the owners unless they directly observe the injury when it takes place. Veterinarians and technicians often identify fractured teeth incidentally while performing routine oral examinations.

Physical and radiographic evaluations are essential to determine the best treatment option for an individual fractured tooth. Conscious oral exams performed in the exam room are of limited value. A complete, more thorough evaluation must be performed while the patient is anesthetized.

Once the patient is anesthetized, physical evaluation can be performed and dental radiographs obtained. A pointed dental explorer is used to probe the dental tissues for loose fragments, cracks, and to assess whether the fracture has exposed the pulp chamber (complicated fracture). A periodontal probe is used to evaluate the extent to which a slab fracture extends below the gingival margin. Transillumination can help reveal vertical fractures as well as determine tooth vitality. A vital tooth will have a translucent appearance while a non-vital tooth may appear opaque. Dental radiographs are necessary to complete any tooth evaluations, and to directly assess whether or not there are root fractures or if an apical periodontitis is present.

Enamel Fractures: A simple crown fracture involving just the enamel may only require smoothing the enamel with a fine diamond bur in a water-cooled, high-speed hand piece.

Uncomplicated Crown Fractures: These are defined as fractures that include both enamel and dentin layers of the tooth, however, there is no pulp exposure. Treatment goals are to protect and restore the tooth by using layers of bonded dental sealants and composites. After the tooth is smoothed and the enamel beveled, the fractured tooth is cleaned, polished with flour of pumice, etched, and treated with a bonded dental sealant. A composite filling material can then be placed over the fracture to restore the tooth and provide an additional protective layer. Some uncomplicated fractures may actually occur at a depth where a “near pulp exposure” has occurred (pink spot in the dentin over the area of the pulp chamber). For treatment, an additional protective layer for the pulp may be indicated. Once the near pulp exposure is treated, the fractured tooth can be restored as previously described. Even uncomplicated crown fractures may traumatize the pulp to the degree that it eventually becomes non-vital (necrotic). Follow-up radiographs are indicated.

Complicated Crown Fractures: These are defined as fractures that extend into and expose the pulp. If the pulp exposure is recent (24-48 hours since exposure in a mature dog, or up to 2 weeks exposure in a dog less than 18 months of age), vital pulp therapy (VPT, partial pulpectomy, and directly medicating the pulp) may be a treatment option. After performing VPT, the tooth is restored with adhesives and composites as described above. If the fractured tooth with pulp exposure does not meet the criteria for partial pulpectomy and pulp capping, then root canal therapy is indicated before restoring the fractured tooth. Any non-vital tooth will become infected. It is only a matter of time. Because of this, from the patient’s perspective, the “wait and see” treatment option approach is incorrect and inappropriate. The pulp must be removed and is done so by either extracting the tooth or having a root canal procedure performed.

Crown-Root Fractures: This type of fracture is often encountered with the classical “slab-fracture” of the upper 4th premolar in dogs. In these cases, the root fracture component disrupts the normal gingival/periodontal attachment around the tooth. This predisposes to focal, chronic periodontitis problems. Therefore, treatment decisions for the tooth need to reflect consideration for the ongoing periodontal health of the tooth.

Root Fractures: These may destabilize the tooth and the crown may be loose. Often, however, root fractures are discovered incidentally on intra-oral radiographs. In most cases, endodontic complications will occur and the treatment option of choice is removal of both the crown and root segments.

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Antimicrobial Therapy for Veterinary Dental and Oral Surgical Procedures

The use of antimicrobial drug (AMD) therapy by veterinarians after oral/dental procedures is very common practice. In most cases this use is not necessary. A major concern is the emergence, spread and high prevalence of multidrug-resistant (MDR) pathogens. This is believed to be associated with the frequent use of AMDs(1). The use of AMDs provides selective pressure on MDR pathogens to evolve. The excessive and frequent use of AMDs in companion animals may be a risk factor for MDR zoonotic infections in people including veterinary hospital personnel(1). Stewardship practices for AMD use in companion animals is needed to slow the emergence and spread of MDR bacteria among humans and animals(1). It is recommended that every veterinary medical record include a justification for AMD use in an animal(2).

Important General Principles for AMD use for Veterinary Dentistry and Oral Surgery:

  1. Plaque is a biofilm. It must be remembered that for most oral infections (especially periodontal disease) you are dealing with organisms in a biofilm environment and not in their planktonic forms. The biofilm protects organisms from AMD attack. Concentrations of antibiotics may have to be up to 1000 higher to be effective against biofilms. There are multiple, separate biofilm environments within the oral cavity. The supragingival and subgingival environments harbor differing biofilms. Due to the biofilm environment and to the number and variety of oral organisms, culture and sensitivity testing are usually unreliable and not feasible.
  2. AMDs should never be used as a monotherapy. Although periodontal disease is caused by bacteria, AMDs should not be the primary treatment strategy(3). Therefore, the mechanical disruption of plaque (dental scaling/polishing) prior to local or systemic AMD delivery is needed to obtain effective results. To do otherwise is an inappropriate use of AMDs and selective pressure for MDR is increased. The days of “pulse antibiotic” therapy are over. This is an inappropriate use of antibiotics.
  3. Systemic antibiotics (Ab) enter periodontal pockets via crevicular fluid flow and oral infection sites via secretion in the saliva. These are round-about means of delivery. Crevicular fluid exchange is 40X/hour and is increased when inflammation exists. Therefore, the Ab contact time is markedly limited.
  4. The “gold standard” for prevention and control of periodontal disease remains professional supragingival and subgingival dental scaling followed by daily toothbrushing. Oral hygiene at home may be enhanced by utilizing special diets, chew objects and antiseptic rinses; however, these methods are not as effective as toothbrushing and are not designed to replace toothbrushing.
  5. The long held belief that oral infections (particularly endodontically treated teeth) result in systemic illness or cause disease processes in distant locations, does not have scientific merit(4). This concept often drives recommendations for systemic AMD use. Therefore, most prophylactic AMD use in dentistry has no scientific basis.
  6. Because of the excellent blood supply, wound healing in the oral cavity is rapid and uncomplicated. Therefore, infectious complications are uncommon.
  7. Antibiotics are recommended for patients with existing medical conditions (EMC). Patients with compromised immune systems may be at higher risk for anticipated bacteremias progressing to overwhelming septicemias. These patients include patients undergoing chemotherapy, have FIV and/or FeLV infections, have poorly controlled diabetes or have other debilitating diseases(4,5).
  8. Oral surgery cannot be considered sterile. Most oral surgeries are either clean-contaminated or contaminated (dirty).
  9. Minor lacerations rarely require AMDs. Deeper and/or more heavily contaminated wounds may benefit from AMDs.
  10. Antibiotics are indicated for most patients with local and systemic signs of established infection (i.e. pain, swelling, pus formation, lymphadenopathy and elevated WBC).
  11. There is currently no scientific support for the previously held belief that there is an association between bacterial endocarditis and either dental/oral surgical procedures or oral infections in dogs(5).
  12. The American Heart Association only recommends antibiotic prophylaxis for dental procedures as being reasonable for patients with prosthetic cardiac valves, previous infectious endocarditis and some forms of repaired congenital heart diseases(6).
  13. Postoperative oral antibiotics are not routinely recommended for patients undergoing extractions. A perioperative dose may be considered for patients requiring multiple surgical extractions with osectomy, those with severe, generalized periodontitis, and/or patients with medical conditions which might impair their ability to clear anticipated bacteremia(5).
  14. In some patients with severe periodontitis, antibiotic use for a few days prior to the procedure may be indicated to reduce periodontal inflammation(5).
  15. Unless there are indications because a patient has EMC, there is no justification for using prophylactic antibiotics for patients undergoing periodontal surgery(5).
  16. Locally delivered AMDs may be very beneficial. 0.12% chlorhexidine gluconate is considered the “gold standard” of topical AMDs. This agent binds to teeth, oral mucosa, pellicle and saliva (high substantivity). It binds to and damages bacterial cell membranes (bacteriocidal).

References:

  1. Baker, S.A., Van-Balen, J., et al. Antimicrobial drug use in dogs prior to admission to a veterinary teaching hospital. JAVMA, 2012;241.
  2. AVMA website. Guidelines of veterinary prescription drugs.
  3. Radice, M., Reiter, A. Evaluation of Subgingival Bacteria in the Dog and Susceptibility to commonly used Antibiotics. J. Vet. Dent, 2006;23.
  4. Tong, Darryl C. Antibiotic Prophylaxis in Dentistry. J. Am. Dental Assoc. 2000;131.
  5. Verstraete, Frank JM. & Lommer, Milinda J. (editors). Oral and Maxillofacial Surgery in Dogs and Cats: Antibiotic use in oral surgery. Saunders-Elsevier 2012.
  6. Wilson, W., et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. 2007;116.