| CASE OF THE
MONTH |
|
(December
2007) |
|
|
|
Signalment
and History: |
|
|
A three year old spayed
female Norwich Terrier was presented by the
owner for a dental prophylaxis with no specific concerns
regarding her oral health. The oral evaluation in the
exam room revealed no marked pathology. The exam showed
light calculus and a gingivitis index of one. The most
remarkable finding was the absence of nine teeth.
Procedures: The patient was placed under general
anesthesia and a complete oral exam was performed. Upon
examination with the periodontal probe, severe
periodontal pocketing was found in the area of all four
maxillary molars and all four remaining mandibular
incisors. Intraoral radiography showed that all of the
missing teeth were indeed truly missing. In addition,
the radiographs revealed severe bone loss of the
maxillary molars and mandibular incisors. All of these
teeth were extracted and the surgical sites were closed
with 4-0 Monocryl. |
|
 |
|
Discussion: One of the most
difficult aspects of providing good dental care to our
patients is attempting to assess the extent of oral
pathology while the patient is awake in the exam room.
This case is a perfect example. In this case it appeared
that the patient had no serious oral disease at all.
After placing the patient under general anesthesia, it
soon became quite evident that she was suffering from
Stage IV periodontitis. The initial assessment of the
patient’s oral condition without anesthesia had no
bearing upon the reality of the situation at all.
Unfortunately this is a very common occurrence in all
veterinary practices, including my own. It is very
important that the owner be made aware of this
difficulty before the procedure is started. Although I
always attempt to provide the owner with my best guess
as to the extent of pathology in the exam room, I always
emphasize emphatically that “The real exam begins under
anesthesia.” Even in a patient that is very cooperative
while awake, we will often miss serious oral pathology
until the patient has been anesthetized. |
|
 |
|
The number one reason that
clients decline to have dental procedures performed upon
their pet is the fear of the danger of general
anesthesia. Naturally they would be very happy if oral
health procedures could be effectively performed without
that dreaded general anesthesia. This has led to a
situation in California where groomers are offering
“dental cleanings” without anesthesia. Even some
veterinarians offer similar services. While this may
appeal to the fearful client, there are many
shortcomings associated with this type of procedure. |
|
 |
|
We have already seen that
very serious oral disease is easily overlooked with such
a procedure. In addition, the removal of calculus found
on the crown of the tooth is merely cosmetic in nature.
It has NO beneficial effect for the patient. The plaque
that causes periodontal disease is found subgingivally,
not on the crown of the tooth. The only way to remove
subgingival plaque and calculus is by using sharp hand
instruments or ultrasonic scalers under the gingival
margin. This procedure is uncomfortable and frightening
to a patient that is not under general anesthesia. As a
result, an awake patient will not receive a thorough
subgingival prophylaxis and will be sent home with the
same disease-causing plaque that he or she came in with.
Not only does the patient receive an inadequate
treatment, but the client leaves with a false sense of
security. The client feels good because he or she thinks
they have done a very good thing for their pet while
avoiding the danger of anesthesia. Therefore they will
take their pet home with the misconception that the oral
cavity is clean and disease-free, and that nothing needs
to be done until the annual cleaning next year.
Meanwhile, the subgingival plaque is destroying the
periodontal tissues, and by next year the situation will
become much worse. |
|
|
|
I tell my clients that this
situation is much like having a fire in your home. You
call the fire department and they quickly arrive on the
scene. They immediately put out the smoke to make you
feel better, but when they drive away, the fire is still
burning. |
|
 |
|
Unless a patient is under
general anesthesia and intubated, there is a very real
danger of aspiration of water, saliva, calculus, or an
extracted tooth. I am sure many of you will remember a
case written up in JAVMA a few years ago that showed a
thoracic radiograph with an upper 4th premolar sitting
snugly in the trachea. |
|
|
With the advances in
anesthetic protocol and pain management in recent years
most of the dangers formerly associated with general
anesthesia have been removed. By utilizing a thorough
physical examination and pre-anesthetic bloodwork, we
can identify most potential anesthetic problems before
they occur. By using balanced anesthetic protocols,
supportive measures such as intravenous fluids,
thermoregulation with warm water circulating blankets
and Bair Huggers, extensive monitoring systems, and pain
management
including regional blocks, we have enhanced the safety
of general
anesthetic procedures. It is the duty of all of us to
properly educate our clients on the safety and necessity
of general anesthesia as an important tool to properly
diagnose and treat oral disease. |
|
 |
|
The
American Veterinary Dental College has issued a Position
Statement on
“Anesthesia-Free Dentistry.” The full text can be read
at: http://
www.avdc.org/dentalscaling.html.
COMMUNITY ANIMAL HOSPITAL
John A. Koehm, D.V.M., F.A.V.D.
Fellow of the Academy of Veterinary Dentistry
4871 Summit Ridge Drive
Reno, NV 89523
(775)-746-0333
|
|
|
