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DENTAL AND ORAL SURGERY FOR PETS

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I used to publish a newsletter call The CUSP. This page contains links to the educational articles published in that newsletter as well as links to some of my YouTube videos.

Each article has the date of original publication or its latest update in the footer.

Articles/Video are sorted into broad categories as follows:
General Anatomy and Physiology
Periodontal Disease and Home Care
Endodontic (Pulp) Disease
Extraction Techniques and Tips
Developmental Problems
Traumatic Injuries
Other Oral Pathology
Feline Issues
Intra-Oral Dental Radiology 
Equipment
Miscellaneous Topics

Some articles appear in multiple sections as appropriate.

There is a collection of one-page client information sheets on several of the subjects on the Forms & Handouts page as well.

 

GENERAL ANATOMY AND PHYSIOLOGY

A Healthy Mouth

This photo essay shows properly shaped and proportioned teeth in a properly shaped and proportioned set of jaws. This is normal (desirable) oral/dental anatomy.

The Tooth

Discusses the basic anatomy of  and the tissues that comprise the tooth.

The Anatomy and Physiology of the Periodontium

Understanding, preventing and treating periodontal disease depends in understanding the structure and behaviour of the periodontal tissues.

Endodontic Anatomy & Physiology

A brief introduction to the world inside the tooth - the world of dental pulp.

Juvenile Veterinary Dentistry

Puppies and kittens are subject to a number of dental and oral concerns. Early recognition and treatment of these conditions can often prevent more serious problems and the pet grows.
Focus on the Mandibular Symphysis In dogs and cats, the right and left mandibles are connected to each other by a cartilage plate in the centre of the chin. Damage to this plate requires careful assessment to determine the appropriate mode of treatment.

PERIODONTAL DISEASE

The Anatomy and Physiology of the Periodontium

Understanding, preventing and treating periodontal disease depends in understanding the structure and behaviour of the periodontal tissues.

Periodontal Anatomy & Progression of Disease
(Video)
While I deal with and use the language of periodontal disease all the time and am very familiar with it, it occurred to me that I may be throwing around terms that pet owners have never heard and it could be baffling for them (like when my accountant tries to explain things to me). So, this video outlines (in a simplified form) the normal periodontal anatomy and the progression of periodontal disease.
Why Is Periodontal Disease Still So Common? Periodontal disease remains rampant in the pet population. How can this still be so in this age of dental enlightenment?
Periodontal Disease is Hidden Periodontal disease is not only the most common health problem in cats and dogs, it is also largely hidden from view below the gum line. The only way to accurately assess and treat periodontal disease is by anesthetizing the patient to allow for a thorough and detailed examination with probing, charting and intra-oral dental radiography.
You cannot prevent disease that is already established. Another case-based illustration of how important it is to start a multi-faceted approach to periodontal disease BEFORE there are signs of trouble. Also, you cannot treat periodontal  disease with measures that are intended to prevent it.
Dental Crowding and its Effect on Periodontal Health Small dogs have proportionally large teeth resulting in dental crowding that dramatically increases the risk of developing periodontal disease. Selective removal of less important teeth can improve the prospects for the more important teeth left in place.
COHAT Defined COHAT stands for Comprehensive Oral Health Assessment and Treatment. This paper outlines the 23 steps involved in the procedure. 
Pericoronitis A discussion on the periodontal consequences of having a tooth partially un-erupted or under-erupted.

Periodontal Disease in Diabetic Patients

Periodontal disease can be difficult to manage at the best of times. Diabetic patients pose extra challenges.

Home Care Concepts and Products

Dental Home Care can be a very important part of maintaining good oral health. As with everything, the benefits are only realized if it is done properly. This collection of articles will help you get off on the right foot.
Reasonable expectations for dental home care There are several good strategies and products to aid in daily home plaque control to help keep a healthy mouth healthy. However, NONE of these products/strategies will treat established disease and none are 100% effective all on their own. It is important to have reasonable expectations for what these products/strategies can achieve.

Why tooth brushing can be worse than useless
(
Video)
Tooth brushing, dental diets and chews are often recommended as aids in maintaining good oral health for dogs and cats. But did you know that none of these strategies will treat established disease and if used in a diseased mouth, may cause considerable pain? Please watch this video to an explanation why tooth brushing (and other mechanical plaque control strategies) can be far worse than useless.
VOHC SEAL The Veterinary Oral Health Council confers their seal of acceptance to products that have shown valid research to back their claims of being helpful in controlling plaque and/or tartar. Learn more about the VOHC from this paper or by visiting www.vohc.org
CUPS Chronic Ulcerative Paradental Stomatitis is a frustrating and painful condition that requires aggressive management. Unfortunately, potions, lotions, rinses and pills will fail to give relief. Aggressive mechanical plaque-control on a daily basis or whole-mouth extraction was required to give these animals a mouth free from pain and infection.
healthymouth(tm)
There are many products on the market that claim to aid in the prevention or even treatment of dental disease. Most are worse than useless. This product, which has the VOHC seal of acceptance for plaque control is of value

Doxirobe(tm)

New research suggests there is no clinical benefit in using locally applied doxycycline or clindamycin in the treatment of moderate periodontal disease in dogs.
Sanos(tm) This is a product that became available in Canada in January of 2013. Applied in hospital in the anesthetize patient immediately after a COHAT, it is considered a "Veterinary Dental Sealant" that is reputed to reduced plaque and calculus accumulation at and below the gum line. 
OraStrip(tm) OraStrip(tm) QuickCheck Canine is an in-office diagnostic test designed to detect early stages of periodontal disease so intervention can be undertaken before there is serious damage.
Surgical treatment of an infra-bony pocket at the lower canine tooth of a cat
(Video)
This 12 minute video demonstrates the surgical management of an infra-bony periodontal pocket at the lower canine tooth of a cat. It is not intended to teach the viewer how to perform this advanced periodontal surgery but more as an introduction to what is involved
Probing Depth Measuring probing depth is an essential part of every detailed dental examination. But how do you do it and what is "normal"? This paper attempts to shed some light.
Cleaning House Old animals with a long history of periodontal disease are often best served by having all their teeth removed to avoid the need for future anesthetics and to avoid chronic infection.

ENDODONTIC (PULP) DISEASE

Endodontic Anatomy & Physiology

A brief introduction to the world inside the tooth - the world of dental pulp.

Vital Pulpotomy Vs. Total Pulpectomy

This article looks at the issues to consider when deciding how to manage a fractured tooth. Read the Endodontic Anatomy & Physiology article first.
Follow-Up Radiographs
for Vital Pulp Therapy
With most general practices now equipped to do intra-oral dental radiographs, we are asking the primary care veterinarians to obtain the follow-up radiographs for vital pulp therapy cases and send the images to us for assessment. This bulletin outlines what we are looking for.
Endodontic Diagnosis Deciding if a tooth has endodontic disease (disease of the pulp) is sometimes very simple and other times quite difficult. This paper looks at some of the criteria for determining if a tooth needs endodontic treatment (or extraction) or not.
The Chevron Sign A common radiographic finding in larger dogs which is easily confused with signs of endodontic disease yet is just a variation on normal.
Uncomplicated Crown Fractures Crown fractures are designated as 'complicated', meaning the pulp is obviously exposed and 'uncomplicated', meaning there is no gross pulp exposure. As this paper indicates, assessing and coming up with a treatment plan for uncomplicated crown fractures is often more complicated that for complicated crown fractures. Confused? Then read on.
What is Root Canal Treatment? Teeth with endodontic (pulp) disease need root canal therapy or extraction. But what is root canal therapy and how is it done?
One tooth, many lessons
(video)
This video talks about four lessons offered by the case of a Bernese mountain dog referred for assessment and treatment of a discoloured upper canine teeth. Spoiler alert, it was a win, win, win, win situation.
Pulp Exposure Requires Treatment
(video)
When a tooth is worn or fractured and suffers pulp exposure, it absolutely requires endodontic therapy or extraction. There are no other medically-acceptable options, least of all, "monitoring" the situation. This video explains why.

EXTRACTION TECHNIQUES AND TIPS

Extraction of right maxillary canine tooth in a 44 kg Mastiff
(Video)

Extraction of maxillary canine teeth is a common surgical procedure and there are a variety of ways of approaching it. Many instructors and resources advocate the use of vertical releasing incisions and the removal of a great deal of bone. I do NOT. In this video, I remove a large canine tooth from a large mature dog with a conservative envelop flap and very little bone removal.
Extraction of the right upper 4th premolar tooth in a mature Labrador
(Video)
This 23 minute video demonstrates (in real time) the extraction and wound closure of tooth 108 using an envelop flap. I use no vertical releasing incision and only very minor bone removal.
Extraction of the lower left 3rd and 4th premolars and 1st molar in a GSD
(Video)
These three teeth all had coronal damage and/or radiographic evidence of endodontic disease but were periodontally healthy and so could be considered challenging extractions. A relatively conservative approach, patience and persistence did the trick.
Extraction of an uncooperative lower canine tooth in a cat
(Video)
This is the video you have been waiting for. How do I go about extraction lower canine teeth in cats when they don't want to come out?

Sutures, Suturing and Flaps

Extraction sites should be sutured for optimum post-operative comfort and healing. This article discusses my preferred suture material as well as flap design and suturing techniques.
Envelop Flaps Why to avoid vertical releasing incisions whenever possible.

DEVELOPMENTAL PROBLEMS

Juvenile Veterinary Dentistry

Puppies and kittens are subject to a number of dental and oral concerns. Early recognition and treatment of these conditions can often prevent more serious problems and the pet grows.
Stop Brachycephalism, Now! This paper may win me many enemies, but after 30 years in practice, I can stay silent no longer. Brachycephalic breeds suffer their entire lives because of serious craniofacial deformities that are imposed upon them in the name of esthetics and cosmetics. As advocates for animal welfare, I believe veterinarians must start informing the public about this very real animal health issue in the hope of changing attitudes and breed-choice habits.
More on Brachycephalism These eleven, richly illustrated pages outline many of the oral problems seen so commonly in brachycephalic animals. It is seeing the suffering resulting from these issues that inspired me to speak out on this subject. In reading this paper you will learn about the problems, how to recognize them and what can (in most cases) be done to mitigate the suffering.
Furry Palate
(video)
This video highlights a common, hidden and lesser-known problem found in the mouths of short-faced (brachycephalic) dogs - fur entrapment in the deep palatal folds.

Pro-Active Dental Care

This paper reports on the difference in oral health between two littermates living in the  same home, one of whom had pro-active dental care at seven months of age and the other who did not. The results are compelling.

Malocclusions 

Overbite, Underbite, Wry Bite, Lance Canines, Parrot Mouth... Malocclusions can take a lot of forms. One thing that is fairly consistent, however, is that anytime there is abnormal tooth-to-tooth or tooth-to-soft tissue contact, something needs to be done to allow the pet to have a comfortable mouth.

Lance Canines

Shelties are very prone to a developmental problem with the placement of the maxillary canine teeth.

"Missing" Teeth

According to the textbooks, dogs should have 42 adult teeth and cats should have 30. Sometimes they are missing one or more teeth and sometimes there are teeth hiding. Hidden teeth need to be found and removed or serious problems can arise.
Dentigerous Cysts When an adult tooth fails to erupt, it will often lead to the development of a large, destructive dentigerous cyst. This should never be allowed to happen.
Focus On: Micro Dogs Small dogs are subject to a wide variety of dental and oral abnormalities in need of identification and treatment.
Microdog Video This video (just over 30 minutes) covers a start-to-finish pro-active procedure in an 8.5 month old Havanese pup to manage her many developmental anatomic dental problems
Focus on: Soft Tissue Impactions Sometimes teeth have trouble erupting because the overlying gingiva is very tough and fibrous. Early intervention is the key.
Crown Reduction When a malocclusion results in the lower canines traumatizing the palate, often, a crown reduction procedure is indicated to alleviate the problem.
Ball Therapy


Ball Therapy Case

A simple technique for the management of mild linguoversion (base narrow) mandibular canine teeth.

A short case report showing how ball therapy helped a young mastiff with base narrow mandibular canine teeth.

Ethics & Orthodontics

Every animal is entitled to a comfortable bite, but they do not need a perfect bite. Performing cosmetic orthodontic work on pets raises a number of ethical issues.

TRAUMATIC INJURIES

Avulsion and Luxation Teeth traumatically torn from their sockets constitute a serious, time-sensitive dental emergency. What should you do and what should you not do when this injury occurs?
Focus on Mandibular Fractures Fractures of the mandible in dogs and cats provide some interesting challenges. This article outlines my opinion on what to do and what to avoid when treating these serious injuries.
Mandibular Fracture in a Puppy This paper outlines management of a traumatic mandibular fracture in an 8-week-old puppy using a series of nylon muzzles.
Radiographic Interpretation:
Case 1
A case study of the management of a mandibular fracture complicated by mis-interpretation of the pre-operative radiographs.
Fractured Primary Teeth Primary (baby, deciduous, milk) teeth are thin-walled and delicate, putting them at risk for fracture. When this happens, they require immediate, complete and careful extraction. This paper explains why.

Vital Pulpotomy Vs. Total Pulpectomy

This article looks at the issues to consider when deciding how to manage a fractured tooth. Read the Endodontic Anatomy & Physiology article first.
Focus on the Mandibular Symphysis In dogs and cats, the right and left mandibles are connected to each other by a cartilage plate in the centre of the chin. Damage to this plate requires careful assessment to determine the appropriate mode of treatment.

OTHER ORAL PATHOLOGY

Dental Caries Tooth decay (caries, cavities) does happen in dogs. This article briefly describes the causes, diagnosis and treatment of cavities in dogs.
Restoration of a Caries
(Video)
While caries is not terribly common in dogs, it can occur. My paper on this can be found here - Dental Caries. This ten-minute video demonstrates the preparation and restoration of a caries lesion in the left maxillary first molar tooth in a dog. It is NOT intended to teach anyone how to do this - it is just to familiarize the viewer with the steps involved.
Focus On Boxers Boxers are great dogs, but they have messed-up mouths. Here are just some of the highlights.
Focus on: Dental Resorptive Lesions in Dogs Most of us are aware of the dental resorptive lesions in cats. Well, as nasty as those are to deal with, they are nothing compared to what can happen in dogs. (way more teeth to deal with).
 Gingival Hyperplasia A discussion of the causes, significance and treatments of gingival enlargements.
Gum Chewer Syndrome Also known as traumatic buccal or sublingual granulomas, this condition arises when animals chew on the lining of their cheek or excess tissue under the tongue. Once bitten, the tissue becomes inflamed and enlarged, making it hard for the animal to avoid chewing on it more, causing more inflammation and pain.
Enamel Hypoplasia If the cells responsible for the production of dental enamel are prevented from doing their job properly, enamel hypoplasia is the result.

FELINE ISSUES

Tooth Resorption in Cats Tooth resorption in cats continues to be a painful, frustrating, mysterious, controversial and very common problem in cats. This paper outlines my current thoughts on the subject as of August, 2012.
Feline Chronic GingivoStomatitis A very painful, frustrating and mysterious feline disease that requires early and aggressive surgical management.
Chemotherapy for SCC? Ginigval squamous cell carcinoma is a common and terrible disease in cats. Off-label use of a drug from Pfizer is showing some promise.
A Feline Malocclusion A short piece on one particular and relatively common malocclusion seen cats.
Lip Entrapment When cats lose their upper canine they are inclined to bite their upper lip with their lower canine.
Feline Gum Chewer Syndrome Malocclusion and/or the loss of the lower molar in a cat can lead to a recurrent and painful ulceroproliferative lesion on the lower jaw. Treatment involves removing the offending upper teeth.
Feline Knees and Teeth Syndrome This is not my work. It is a short poster-presentation on an odd condition in which persistence of primary premolars in cats has been linked to spontaneous patella rupture and possibly other skeletal issues later in life. More work to be done on this

INTRA-ORAL DENTAL RADIOLOGY

Radiography Tip & Tricks This paper was actually published in the CanVetJ, Feb, 2018 but is available as a free full text version, so I am posting the link here. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764209/
Radiograph Labelling Whether using analog film, digital or computed radiography each image MUST be clearly labeled with clinic name, patient identification, date and time, anatomic region.
Thoughts on Radiology Intra-oral dental radiology will become the standard of care. Get in front of the curve by incorporating this essential diagnostic tool into your dental practice now.
Why should you do whole-mouth radiographs? If you are equipped and trained to obtain and interpret intra-oral dental radiographs, that is super. But are you doing whole-mouth studies on all of your dental patients? If not, it is time you started.
Why Intra-Oral Dental Radiographs are Essential
(Video)
This is a 43-minute video of me presenting my lecture on why intra-oral dental radiographs are essential for ALL dental patients. I mean, whole-mouth intra-oral dental radiographs pre-operatively for all patients and post-op images of any surgical sites well as as many intra-op images as you need.
Analog vs Direct Digital vs Indirect Digital While the need for intra-oral dental radiography cannot be disputed, which technology to embrace is a hotly contested topic. Here are my thoughts and observations.
The Chevron Sign A common radiographic finding in larger dogs which is easily confused with signs of endodontic disease yet is just a variation on normal.
Radiographic Interpretation:
Case 1
Getting diagnostic intra-oral radiographs is certainly important but is only half the battle. Accurate interpretation of the images is equally important. This case illustrates this point.
Separating Roots Imaging all three roots of the maxillary fourth premolar can be a challenge as the mesiobuccal root is often superimposed over the palatal root. This short document demonstrates away to see around this problem using parallax shift.
Normal Canine Dental Radiographs This is simply a set of normal intra-oral dental radiographs of a 30 kg, 4 year old cattle dog cross.
Normal Feline Dental Radiographs This is simply a set of normal intra-oral dental radiographs of a 4 kg, 1.5 year old cat.

EQUIPMENT

Dental Waterline Disinfection The water lines in dental equipment can be a cesspool of bacteria. This unsolicited article describes a very simple system for keeping dental water lines clean.
Shopping List A brief run down on the essential equipment list for your dental department.
Sharpening I
(Video)
All dental instruments need to be inspected and sharpened after EVERY procedure prior to being autoclaved. This video from Hu-Friedy outlines how to sharpen dental scalers and curettes.
Sharpening II
(Video)
All dental instruments need to be inspected and sharpened after EVERY procedure prior to being autoclaved. This video (done by me) outlines how to sharpen dental and periosteal elevators.
Digital Camera A good digital camera is essential for so many things in practice. This paper introduces you to the one I am using currently.

MISCELLANEOUS TOPICS

How to Send Images
for Telemedicine
Owners and veterinarians often call looking for advice on cases. Sending some images, as outlined in this paper, can really help me help you. Page six is a synopsis/review of the important steps to follow. Post it in your practice for reference.
Whole Mouth Extraction for Everyone This is a bit out there and is mainly meant to make a point, but there is actually some logic to it. Have a look.
Whole Mouth Extraction
Part 2
Whole mouth extraction is a very common procedure at Hale Veterinary Clinic. This paper looks at some of the reasons why and gives you some things you can share with your clients to help them understand why it might be the best option for their pet.
Anesthesia-Free Dentistry I have discussed the perils of anesthesia free dentistry before, but it is a problem that seems reluctant to go away, so here is a call to arms from 2013.
Video on Anesthesia-Free
Teeth Cleaning
In this video I discuss and explain my views on anesthesia-free teeth cleaning and explain the current legal aspects of this in Ontario at the time of recording in April of 2020.
RCVS Statement on
Anesthesia-Free Dentistry
The Royal College of Veterinary Surgeons also has a strong statement condemning Anesthesia-Free Dentistry and here it is.
AAHA Dental Care Guidelines In 2005, the AAHA published their Dental Care Guidelines for Dogs and Cats. It was updated in 2013 and then again in 2019. Here is that latest version.
Treat or Extract The decision whether to extract or treat/salvage a diseased tooth is based on consideration of many factors as outlined here.
The Knee-Cap Rule People frequently ask for advice on what they can let their dog's chew. I typically tell them about the Knee Cap Rule. It is explained here. 
Bones This two-page notice is from the FDA website and outlines ten good reasons why you should never give your dog bones to chew on. The number one reason stated is fractured teeth. The other nine are nasty as well.
CVO Statement The College of Veterinarians of Ontario is the licensing and regulating body for veterinarians in the province of Ontario. Canada. In the fall of 2008 they published a Position Statement on Veterinary Dentistry and this paper examines some of the highlights.
Phone Estimates A brief explanation of why any relationship between a phone estimate and the actual invoice is purely coincidental.
Team Work Providing optimum client and patient care is a team-efforts. This is a guide for the referring veterinarian regarding what you can to do for me and what I will do for you so that we can both do the best for your patients and their owners.

Dental Mythology

From some of the questions I get, it is apparent that there are still a number of misconceptions about dental issues. This article should help dispel some of these myths.

Mythological Creatures

There is no such thing as a "routine dental prophy" and "tooth root abscesses" are as rare as hen's teeth.
Dental Truths The other side of the dental mythology coin, this piece outlines some things that are very well known to veterinary dentists, but may not be common knowledge among general practitioners and pet owners.

Ethics & Orthodontics

Every animal is entitled to a comfortable bite, but they do not need a perfect bite. Performing cosmetic orthodontic work on pets raises a number of ethical issues.

Antibiotics in Veterinary Dentistry

In my opinion, antibiotics are often worse than useless in the management of dental and oral disease. In the same vein, culture and sensitivity are almost never going to yield clinically useful information.
Why Antimicrobials are of such limited use Antibiotics and antiseptics are often used in an attempt to manage periodontal disease but they simply do not work. This paper explains why. Unfortunately, some of the links in this paper may have gone stale, but you will still get the idea.

The Role of the Veterinary Technician in the Delivery of Dental Care

The College of Veterinarians of Ontario and the American Veterinary Dental College have guidelines regarding what procedures veterinary technicians should and should not be doing. This article emphasizes the many ways in which a properly trained technician can be a valuable part of the dental care team.
NFCO Many dental procedures are Not For the Casual Operator. This short piece cautions general practitioners to be cautious when undertaking procedures normal done by a specialist (in any area of practice) unless that have taken considerable post-graduate training in that field.
Local Anesthesia While all dental and oral procedures must be done under general anesthesia, local anesthetics are also of tremendous value when performing oral surgery.
B.A.R.F Diets May people are turning to raw diets for their dogs and cats. This article discusses some serious concerns about these diets, whether home made or commercially prepared.
Just Say No to Bad Medicine What to do when we offer a client a choice between Plan A and Plan B (both medically appropriate) and they decline both but request Plan C (not medically appropriate)? The College of Veterinarians of Ontario tells us we are obliged to refuse to provide inappropriate care, even when the owner requests it.
Who Is Responsible? Many breeds are deformed by design. That is to say, they have been selectively bred to have some structural deformity such as short legs (Bassett Hound) or a short maxilla (boxer). If these genetic deformities result in situations that require treatment, who is responsible for paying for that care? Some would suggest that the breeder ir responsible, but the people who purchase these deformed animals need to take responsibility for their breed-choice decision.
Things I tell clients There are several illustrations and analogies I use to help pet owners understand various issues. Here are a few of them. Feel free to use them yourself.
Carrot or Stick

There are a great many excellent medical and business justifications for general practices to offer basic but high quality veterinary dental care (the carrot). There are also a number of reasons to ensure that the level of care you provide is up to current standards (the stick).

The Popularity Paradox Published in the Canadian Veterinary Journal in April of 2015, this paper explains a conflict of interest we are all in. Our clients rely on us for medically accurate assessments and advice, but if we were really truthful, they might find what we have to say troubling and they will stop coming to visit us.
Top Two Questions The most common questions we get when primary care veterinarians or pet owners contact us we "How much will this cost?" and "When can you see my pet/patient?". They are excellent questions and I absolutely understand why people ask them. This bulletin explains why there is no simple answer to either question.
Pre-Visit Medications There are a few drugs that can be given at home the night before and the morning of your pet's/patient's visit to Hale Veterinary Clinic that can make the whole adventure better for everyone involved. This paper discusses that plan.
General Anatomy and Physiology
Periodontal Disease and Home Care
Endodontic (Pulp) Disease
Developmental Problems
Traumatic Injuries
Other Oral Pathology
Feline Issues
Intra-Oral Dental Radiology 
Equipment
Miscellaneous Topics

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