Dental Procedures Offered at CVRC:

When an owner and a patient enter our dental service, we always start with a thorough oral examination and complete physical exam. Many times the patient has been referred to our service by their primary veterinarian for a specific oral problem. We address this problem as well as any other issues that are a concern in the mouth. We will have a discussion together on what is recommended for your special furry family member and the treatment options that are available. We give all clients a detailed estimate of all recommended services before we perform any procedures. In veterinary medicine, often our patients aren’t as cooperative as you or I at the dentist. A much more detailed oral examination with dental radiographs (x-rays) is performed once the patient is anesthetized. We know your pets, just like our own pets, are part of your family. Our goal is to give the same care and attention to your pet as we would our own. Here are some of the procedures that we offer with our veterinary dental services:

1. (Vital Pulpotomy and Therapies) . Endodontics involves treatment of the of the . The pulp contains the nerves, blood vessels and other soft tissues of the teeth. When the of the tooth (visible part of the tooth above the gum line) has been injured (fractured/worn down/changes in color), the pulp often becomes exposed and/or infected by bacteria. This causes an infection within the pulp and can lead to death of the pulp, thus death of the tooth itself. Once a tooth becomes infected, this infection can extend from the root of the tooth into the surround bone of the jaw to create an abscess (area of infection). This is painful and destructive to the surrounding bone of the affected tooth. . If a major tooth is injured in a young patient (less than 2 years of age) and the pulp has been exposed less than 48 hours), a vital pulpotomy may be the treatment of choice. This procedure allows the infected pulp to be removed, a special dressing is placed over the pulp to promote healing in the absence of bacteria and a composite filling is placed to further protect the treated pulp from the bacteria of the oral cavity. This allows the tooth to continue to mature and it is still a living tooth. . Vital pulpotomies are also a treatment for mandibular (lower jaw) canines that are erupting narrower than they should, causing the tips to hit the maxillary (upper jaw) hard . The vital pulpotomies when performed for these “base narrow” canines allow these canine teeth to be shortened in height so that they do not touch the . . If a major tooth is injured and the pulp is exposed or infected in an older patient (over 2 years of age), then the treatment of choice to keep the tooth structure in place and functional is a Root Canal Therapy. This procedure removes all of the infected pulp tissue from the pulp chamber (root canal) itself and then the pulp chamber (where the previous pulp tissue was housed) is cleaned thoroughly to remove all bacteria. The void where the previously infected pulp was removed is filled with gutta percha (just like in humans). A composite filling is also applied to teeth that undergo Root Canal Therapies to prevent any leakage of bacteria into the inside of the treated tooth. A tooth that has undergone a Root Canal Therapy is no longer living and lacks the nerve sensory as a living tooth (thus a patient may not know when to stop chewing, pulling, etc due to the lack of a sensory of pain to stop them—which can often lead to further fractures of these treated teeth). In these cases, we may discuss placing a titanium crown over these treated teeth to make them stronger and prevent further complications.

Vital Pulpotomies for treatment of “Base Narrow” or Linguoverted Canines:

There are defects on the inside of the maxillary Notice the canines of the lower jaw are (upper jaw) canines from the lower canines positioned more narrow than normal hitting the mucosa due to being too narrow.

The crowns of the mandibular (lower canines) The mandibular canines no longer contact have been shortened & had vital pulpotomies. the maxilla (upper jaw).

Adult dog with a complicated crown fracture of the left maxillary (upper) :

This patient has a complicated crown fracture of the This is the same fractured tooth as the previous image, left maxillary (upper) canine. The crown tip has however looking from the back side of the tooth. fractured off, exposing the pulp (nerves, blood vessels Notice the large amount of enamel that has fractured and soft tissues of the tooth). This tooth is non-vital from the back surface of this tooth. and requires treatment to remove the infection and eliminate oral pain.

This is a dental x-ray after the root canal therapy was performed. The infected, diseased and dead pulp tissue was removed. A sterile, inert substance has been placed to fill the previous space where there was pulp tissue (gutta percha)—demonstrated by the bright density on the radiograph.

2. Exodontics (surgical extractions for non-vital and fractured teeth) . Some patients with severe tooth fractures where most of the clinical crown (visible tooth above the gumline) has been destroyed, patients with tooth resorption (breaking down of the structures of the teeth) or severe cavities may require surgical extractions. These affected teeth may not benefit from a Root Canal Therapy due to the condition of the affected teeth and/or surrounding jaw bone and extraction is the best option. We will help guide you into the best treatment for your pet. . Sometimes owners prefer extraction of a tooth over root canal therapy and saving the tooth structure—this is okay too. As long as the affected tooth is treated so that the infection and pain is addressed---you are doing the right thing. It is never okay to just leave or “watch” a fractured or discolored tooth. . Dogs and cats have some teeth that are very large and some have multiple roots. These teeth can be challenging to extract and if not performed properly or with experienced hands, the patient’s jaw may be inadvertently fractured. . Some dogs and cats (more common in cats) suffer from a condition called (infection/ of the oral cavity). Unlike other infections, this condition occurs when a pet’s immune system is very sensitive to the bacteria on the surface of the tooth. These conditions cause the gum tissue to be red, inflamed, and often times ulcerations are present. This disease process is extremely painful for the patient and may lead to the pet not eating, dropping food from their mouth when the do eat, or acting painful while eating. This can be a frustrating disease process and it is best when treated when the first signs are evaluated and after oral examination stomatitis is suspected. The preferred treatment is complete extractions of the teeth (also called total mouth extractions)-- (thus bacteria will not have a place to adhere to and the gum tissue will not be affected). Often times the evening after surgery, these pets are so much more comfortable and eating well with no pain.

Non-vital (dead) left mandibular 1st (endodontic and ):

Gum recession with infection present & malformed tooth X-ray reveals non-vital (dead) tooth with abscess

Non-vital (dead) right mandibular 1st Molar (endodontic and periodontal disease):

Gum recession with infection present & malformed tooth X-ray reveals non-vital (dead) tooth with abscess

3. Jaw Fracture Repairs: . Maxillary Fractures (upper jaw) . Mandibular Fractures (lower jaw) . Fractures of the (TMJ) . Some of our patients find themselves in peculiar situations. Maxillary and/or mandibular fractures can be seen in patients that have been hit by cars, attacked by other animals, suffered trauma from an unknown source, falling from high surfaces, and mandibular fractures can be common in advanced periodontal disease. In veterinary , we tend to use more low profile (smaller fixation devices) including very small wires and/or individualized acrylic splints, etc to stabilize these fractures for optimal healing. We also pay close attention to any teeth that may have been inadvertently fractured or teeth that have roots sitting in the fracture sites---these teeth may also need to be treated and/or addressed in order to obtain complete healing of the fracture site.

Young cat that was attacked by a dog (multiple maxillary fractures):

This patient had many bone fractures of the maxilla (upper jaw) and severe lacerations of the palatal mucosa (soft tissue of the upper jaw). The nasal cavity and multiple nerves were exposed.

After a thorough oral examination and dental x-rays, The multiple fractured bones of the maxilla (upper jaw) the lacerated palatal mucosa was sutured back together. were stabilized using a plastic acrylic splint that was specifically designed for this pet at the time of surgery.

4. Juvenile Dentistry: . Orthodontic problems, if present, often develop in the young patient. Catching these problems early and being proactive about treatment can often reduce the severity of the problem. As a routine part of a puppy or kitten’s first veterinary visits (a good time is during the vaccine booster visits), should include a thorough oral exam each time. These can be the first clues on teeth that are not coming in correctly, are missing or are malformed. . By 6 months of age, in most breeds, all baby (deciduous) teeth should have fallen out and only the adult teeth should be present. If any baby (deciduous) teeth have not fallen out by this time—they should be surgically removed so that the adult tooth can erupt properly. Some puppies and kittens may fracture their baby (deciduous) teeth, exposing the pulp (nerves, blood vessels and soft tissues) of the tooth leading to pain and infection. These fractured teeth must be surgically extracted so that the adult tooth is not damaged and so that the infection does not spread to the jawbone. . It can be common in the toy breed and smaller breed dogs to have retained (baby teeth that do not fall out on their own—allowing for the adult teeth to erupt properly). Sometimes this can cause serious problems including impaction of the adult teeth and surgical intervention in appropriate time is the key for successful management of these cases.

4 Month old Puppy with a fractured deciduous right maxillary 3rd (PM):

Slab fracture of the deciduous right maxillary 3rd PM. Normal deciduous left maxillary 3rd PM.

A pathfinder has been inserted into the fractured X-ray revealing the metal pathfinder extends beyond tooth & root canal, confirming that this deciduous the root of the deciduous tooth and leads to the tooth is non-vital due to the pulp exposure. developing adult tooth bud.

8 Month old Puppy with multiple retained deciduous teeth:

This puppy has adult and deciduous (baby) teeth trying to occupy the same spaces (there appear to be double rows of teeth). This is not normal and the deciduous teeth need to be surgically removed since they did not fall out on their own so that the adult teeth may continue to erupt in a normal fashion.

5. Oral surgery: (Oral mass removal (benign vs. neoplastic/cancer) . The oral cavity is the 3rd most common site for tumors. Often times, these tumors or masses are not found until they are quite large (if a pet doesn’t have a routine thorough oral exam and if an owner is not routinely brushing or evaluating the oral cavity---these masses can “sneak” up on you). Until further diagnostics are performed (oral exam with dental x-rays and biopsy of the mass) it cannot be determined if the mass is benign or cancerous. When patients present with an oral mass, all differentials and treatment options are discussed. If the mass is larger or we need more information before treatment, a biopsy may be taken to find out exactly what type of mass we are dealing with in order to treat appropriately. If the mass is smaller, then it may be recommended to remove it completely and then perform the biopsy to find out what the mass is. Each case and each patient is different and an individualized treatment plan is made for your pet at the time of the consultation. . If a patient presents for a suspected cancerous mass—we will recommend a thorough workup including thoracic (chest) x-rays to make sure that there is no evidence that the suspected cancer has spread and to make sure there are no increased risks for anesthesia for that patient. . Sometimes these surgeries result in taking a large part of the upper or lower jaw to remove the mass and obtain clean margins (free of cancer cells). After the biopsy results are returned, depending on the type of mass we may recommend follow up with an oncologist. At CVRC, we are lucky enough to have an amazing staff of specialists that often work together on a case for the best treatment and outcome for the patient.

Small Oral Mass of the (lower jaw):

Oral mass of the right lower canine Oral mass of the right lower canine After oral mass removal (side view) (looking down over mass)

Large Oral Mass of the Maxilla (upper jaw):

Oral mass of the left maxilla (side view) Oral mass of the left maxilla (straight on view)

After oral mass removal with clean margins

(Oronasal Fistula Repairs): . Oronasal fistulas are a communication between the oral cavity and the nasal sinus. One of the most common sites for an oronasal fistula is in the area of the maxillary canines. Sometimes the tooth is present with an oronasal fistula and sometimes the tooth has fallen out or was extracted and the gum tissue did not heal properly. This abnormal communication should be closed surgically to prevent infection of the nose and in severe cases this could lead to pneumonia.

Oronasal Fistula in a 14 year old dog:

Oronasal fistula present where the right maxillary Surgical planning for the oronasal fistula repair. (upper) canine used to be. This hole leads from the mouth to the nasal sinus and will not heal on its own.

Oral surgery to correct the oronasal fistula. A This mucogingival (gum) flap is sutured over the mucogingival (gum) flap is created with no tension. oronasal fistula for surgical repair. There is no longer communication between the mouth and nasal sinus.

(Cleft Palate Repairs): . Puppies and kittens may be born with a cleft palate. A cleft palate is a defect that can include the hard or soft palate (front to back of the upper jaw) and allows communication of the oral and nasal cavities. This condition can be congenital (happen as the puppy or kitten is developing) or there are also traumatic causes of a cleft palate. . Some traumatic causes of a cleft palate would include but not be limited to: electrical shock and burns from pets chewing on electrical cords, pets chewing on sharp or pointed objects that may perforate the mucosa of the maxilla (upper jaw) or soft palate, foreign bodies (pieces of sticks that may become lodged between teeth, expanding across the maxilla, creating infection of the underlying mucosa and bone). . These patients often sneeze or have food or water coming out of their nose right after eating. If the cleft is present at birth, these puppies and kittens are unable to properly nurse and suckle from their mothers and do not get the nourishment they need to survive on their own.

Traumatic Cleft Palate Repair in a kitten:

Acquired (traumatic) cleft palate of the left maxilla Surgical repair of the cleft palate. A sliding flap of the (upper jaw). This young cat chewed on electrical wires remaining healthy palatal mucosa (tissue on the roof of and was electrocuted, resulting in an electrical burn the mouth) was created to cover the cleft palate (hole). through the upper jaw—exposing the nasal sinus.

Completely healed cleft palate surgery. Often times, these involved cleft palate surgeries may require multiple procedures for complete repair.

Feline Oral Resorptive Lesions (tooth resorption): . The exact mechanism of feline tooth resorption is unknown, however this is a very painful process where the crown or root of the tooth is broken down (resorption) and in many cases there is pulp (houses the nerves and blood vessels of the tooth) exposure causing severe pain. These teeth need to be extracted so that the patient is comfortable. There is continual research to find the cause for these lesions so that we can learn more about this disease process.

Dental x-ray of the left maxillary (upper) canine. The clinical image of the patient’s left Notice the destruction of the crown in this x-ray (does reveals that there is little to no normal crown of this not look like a normal crown). tooth. The surrounding gum tissue has grown into this tooth. This is an example of tooth resorption.

Dental x-ray of the right maxillary (upper) canine in The clinical image of the patient’s right maxillary the same patient. Notice that the canine crown is intact canine reveals recession of the gum tissue and there is and appears normal, there is advanced bone loss exposure of part of this tooth’s root (arrows). (periodontal disease) of this tooth.

6. : . Every patient has the right to have a comfortable bite (meaning that whether their mouth is opened or closed, they should not feel pain or be uncomfortable). Just like in humans, some animals have teeth that don’t erupt correctly (they may be in the wrong position, rotated, or occluding with other teeth or soft tissues in the mouth). Some breeds have been bred to have a longer lower jaw (boxers, bulldogs, etc). If the (“bad bite”) is not causing a problem for the patient, then no medical management or treatment is necessary. . Oral pain in our patients is very subjective and hard to asses. Our pets for the most part try to be strong for us—that is their instinct from the wild (“be strong or be eaten” philosophy). . In patients where their teeth are hitting each other or teeth have not erupted properly or are causing soft tissue damage there are treatment options available. We do offer orthodontic procedures (similar to braces and retainers in humans) that gently move the problem teeth into a more appropriate and comfortable position. These procedures often take months and often visits for results, thus it takes a special dedicated owner for these types of procedures. Otherwise, some can be treated with endodontics or extractions depending on the case. Our dentistry team will always discuss all options available and help you choose the best option based on you and your pet’s lifestyle.

Middle aged dog that presented for severe malocclusion:

This patient’s left mandibular (lower) canine is This orthodontic procedure was performed in stages. misaligned. When the patient closes his mouth, his First the left maxillary (upper) canine was moved back maxillary (upper) left and left canine contact to allow a space for the left mandibular (lower) canine this misaligned left (this is most to occlude. After the movement of the left maxillary likely why it became misaligned. canine was complete, the left mandibular canine was addressed.

An elastic chain attached to brackets that were Once the left maxillary canine was in a more cemented on the appropriate teeth were used to use appropriate position and there was room for the left gentle traction to move the left maxillary canine back mandibular canine’s crown to rest upon occlusion---an (into a more caudal position). elastic band attached to brackets was placed on the left mandibular canine to allow gentle traction and thus movement inwards (toward the tongue).

A couple of months into treatment, the teeth are starting to align in a much more comfortable position for the patient to close his mouth properly.

7. Periodontics: a. Periodontal disease affects the , bone surrounding the teeth and the periodontal ligament (which holds the tooth in place). It often begins as (inflammation of the gums). Periodontal disease has been referred to as the most common disease in domestic dogs and cats. This disease can have an impact on the rest of the body (infections, decreased immune system, diseased organs). b. Periodontal disease is broken down into stages depending on its severity. Many times the earlier stages are reversible with a thorough dental cleaning and commitment to home care (owner’s brushing teeth, etc). In the more advanced stages, teeth may form periodontal pockets that collect calculus (tartar) and bacteria---that cannot simply be brushed away. We perform many periodontal procedures and surgeries to keep the periodontal disease from progressing to the point of a pet’s teeth falling out. Some teeth in the most severe stages of periodontal disease may not be good candidates for periodontal therapy, however as a team (the client and veterinarian) will discuss the best options for the individual patient.

Periodontal Therapy: Bone Grafting in a 5 year old dog:

Ther e is a deep periodontal pocket (bone loss around A gingival (gum) flap was released in order to clean the tooth)—of the left lower canine tooth. This is a out the debris (tartar/bacteria) from this pocket. large and important tooth to save if at all possible. Artificial bone was then placed to promote the jaw to replace the missing bone in the area of the periodontal pocket to make the tooth more stable.

The gingival (gum) flap is then sutured back to normal and the underlying bone is left to heal. This allowed the left lower canine to stay in the mouth and be functional.

Severe Periodontal Disease in a 15 year old dog: Unfortunately due to the severity of the periodontal disease, we were unable to save this dog’s teeth. However once the teeth were extracted--the pet felt much better (was more active than he had been in years), did not have infection overwhelming his immune system and had a better quality of life.

Calculus (tartar) is covering all of the teeth, preventing This is the left upper jaw (side view). The calculus the visualization of some teeth. This is the pet’s harbors bacteria that are toxic to the underlying gum maxilla (upper jaw). tissue, the tooth itself and surrounding jaw bone.

Calculus (tartar) is covering all of the teeth, This is the left lower jaw (side view). Notice the preventing the visualization of some teeth. This thickness of the calculus (tartar) and that the patient’s is the pet’s mandible (lower jaw). hairs are actually adhered to the calculus. Notice the “puffiness” of the diseased gingiva (gingivitis).

8. Prosthodontics: a. Prosthodontics is the branch of dentistry that deals with restoring the constructing of appliances designed to further protect teeth, replace missing teeth and/or adjacent structures. b. Many of the procedures that are available in human dentistry are available in veterinary dentistry, although not all human procedures are practical for our veterinary patients. c. In our clinic, Prosthodontics mainly deals with the preparing for and fabrication of metal crowns for added support for appropriate teeth. The enamel (outer layer of the crown) is the strongest substance made by the body, once the enamel has been worn or fractured—the body cannot produce more enamel. These teeth are more susceptible to wear, fractures, sensitivity, and pulpal exposure depending on the severity of the enamel loss. d. A common presentation of teeth that are worn is seen with dogs that are cage chewers/biters. Some dogs, whether they suffer from anxiety, boredom, high energy working dogs (police dogs), etc—when placed in metal cages, often chew on the metal bars causing wear on the back part of their canines (the big “fang” teeth also called “cusps). With this repeated behavior, the teeth are severely worn and can lead to fractures. If addressed early on with understanding the patient’s needs and redirecting the behavior—this behavior may be modified. However, these worn teeth must be addressed, otherwise the risk of further damage and fracture are high. We often place titanium “metal” crowns on these teeth so that the teeth are protected from further wear. There are now many options for crown fabrications—including a more natural tooth colored crown. Not all crowns are made out of the same material (some are not as resilient as others) and patient selection is key for success. e. As mentioned in the “Endodontic” section---we often apply crowns to teeth that have been treated with root canal therapies in dogs.

Adult dog with a complicated crown fracture of the right mandibular (lower) 1st molar:

Notice the complicated crown fracture on the lingual After treating the fractured tooth with a root canal surface (toward the tongue) of this right mandibular therapy, this tooth had a crown preparation and a (lower) first molar tooth. Many times these fractures titanium crown was fabricated by an outside aren’t noticed because they are difficult to see on the laboratory. This crown was then cemented onto the inside of the mouth. pet’s tooth for added stability and protection of the root canal therapy.

9. Advanced Diagnostics/Testing for: a. Biopsies and appropriate treatments for atrophy/inflammation of muscles of the head: Due to the need for overnight shipping of the biopsy samples to California for laboratory testing (only open during the week) and the need for the biopsy samples to be fresh upon arrival—this procedure cannot be performed on Thursdays or Fridays. Masticatory muscle myositis is an inflammatory disease in dogs affecting the muscles of mastication (chewing). It is the most common inflammatory muscle disease in dogs and mainly affects large breed dogs. Acute symptoms can include: swelling of the jaw muscles, , and pain on opening the mouth. Problems with the eyes can also be evaluated (third eyelid protrusion, red eyes, and/or protruding eyeballs). With chronic masticatory muscle myositis symptoms can include: atrophy (muscle wasting) of the jaw. When scarring of the masticatory muscles occur, this may result in the inability of the pet to open their mouth. The affected muscles include the temporalis, masseter, and pterygoid muscles. The disease is usually found on both sides of the head (bilateral). Diagnosis is made by taking very small biopsies of the affected muscles as well as a special blood screening panel for comparison. Treatment includes oral steroids and tapering to a low, yet effective dose over time. Most pets respond very well to therapy once the diagnosis has been confirmed.

b. Advanced imaging: Skull radiographs/fluoroscopy/CT Scans/MRIs available on site for evaluation of Temporomandibular Joint (TMJ) problems and for further evaluation and proper treatment planning for large oral masses.