Small Animal Dentistry Summary

Dental journey

• identify normal and abnormal

• anaesthesia and analgesia

• diagnosis and treatment - extract, keep, refer

• oral hygiene after procedure

conscious oral examination is not enough 

firm recommendation for further assessment/treatment under GA

discuss costs openly and honestly

never too old for dental treatment

Summary of small animal dentistry

• dental problems often overlooked - no signs of overt pain

• significant source o pain

• correct treatment massively improves health and welfare

• build practical skills gradually

• its ok to refer

Teeth - key words

• root apex

• periodontal ligament

• pulp - produces dentine (odontoblasts)

• crown = enamel & dentine

• cementum

  • gingiva+ gingival margin (tooth side)

  • attached gingiva

    • closely adhered to underlying alveolar bone

    • adjacent → gingival margin

  • flexible gingiva (can be dark brown)

    • useful for open extractions

• mucogingival junction (oral mucosa side)

• alveolus socket

• alveolar bone

• neurovascular bundle

  • maxillary/mandibular AVN

Radiography

• enamel - shiny white thin layer

• dentine - mid-range grey

• pulp chamber - dark central area

  • chamber → canal → apex

• normal jaw bone - mottled

• periodontal ligament - thin black line around root

  • used to assess general tooth health

• furcation = point where multi-rooted teeth (PM&M) branch off from the tooth's main trunk

Normal oral anatomy

• incisive papilla - behind incisors → take pheromones from air

• feline lingual molar salivary gland

  • lump behind feline mandibular molar

  • bilateral - then probably normal

• palatoglossal folds - caudal tongue

• salivary duct openings- below tongue, lateral + behind molars

• oropharynx (tonsils)

• caudal oral mucosa inflammation

  • caudal stomatitis not faucitis

• normal occlusion - interlocking canines

Oral directional terms

Mandibular arcade

• buccal surface (cheek) vs lingual (tongue) surface 

  • e.g. buccal gum surface

• mandibular symphysis

• distal → mandible

• mesial → towards incisor

• labial - gums near lips

Maxillary arcade

• buccal side

• palatal surface

• distal, mesial, labial

• palatine fissures

Teeth

• 42 dog

• 30 cat 

• modified tridan system

  • 1,2,3,4 → clockwise

    • from upper right

  • 04 - canine

  • 09 → 1st molar

Carnassials

• Dog and Cat

  • P4 - max

  • M1 - mand

• Lots of dog pathology - fractures

• less common in cats

Incisors

• 6 max, 6 mand

• grooming (flea comb), nibbling

Canines

• 1 per quadrant

• killing, offence, defence, holding, mating, communication

Premolars

• dog → chopping

• cat → crunching

Molars

• dog → grinding

• cat → cutting

cat - only 1 molar, PMs more max

• count backwards → 09, 08, 07

• max → 3PMs → 06-08

• mand → 2PMs → 07,08

dog 

• all = 4 PMS (05-08)

• mand - more Ms (09+)

  • max - 2MS

  • mand - 3MS 

Dental → comprehensive oral health assessment

• scale → polish → full mouth extraction = oral surgery

• GAs, xrays, scale, polish, extractions if required

History

Cant eat, wont eat

Clinical exam - distance

Clinical exam - gingiva, teeth, plaque vs calculus, soft tissues, extra-oral

Plaque vs calculus

• oral biofilm of bacteria

• invisible unless plaque-closing solution used

• calculus (tartar) - mineralised plaque

  • can hide periodontal disease underneath

• calculus volume NOT proportional to disease

History

• rarely overt presentation

• signalement - age related

• routine visit - other heath issues or oral health complaint

• diet - wet, dry, raw

• toothbrushing? difficult

• chews, toys, habits

  • bones, antlers, tennis balls

Can’t eat, won’t eat

• dental disease → usually good appetite

• unless 1/10 facial swelling, severe oral stomatitis, severe gingival

• or not chewing properly → throwing back up

• oral ulceration local or systemic

• underlying disease process causing inappetence

  • nauseous/unwell

    • kidney disease → can cause halitosis → mistaken for dental disease

  • metabolic, neoplastic

Clinical exam - distance

• greet

• judge temperament

• gloves - professional

• judge symmetry (swelling), muscles, eyes/nose (discharge)

• mouth closed - occlusion plane

  • common upper 08 impinging on lower gum

Clinical exam - focused 

Communication - Firm recommendation

Clinical exam - focused 

Rooted teeth

Root No.	Dog	Cat
1	All Is, all Cs, upper & lower PM1	All Is, all Cs, upper & lower PM2
2	Upper 2+3PM, lower 2–4PM lower Ms	Upper 3PM lower 3+4PM lower M
3	Upper 4PM (carnassial), upper Ms (M3 variable)	Upper PM (carnassial)

Clinical exam - focused 

• check canine - is there build up → lift up lip

• check carnassial teeth → max P4, mand M1

• tongue + soft tissue

• push thumb → tongue rises

  • squamous cell carcinoma → common in cats

• cats: lift up lip, only open up mouth at the end

gingiva,

• gingivitis - inflammation

• gingival recession - more than crown visible

• gingival enlargement

  • can cover tooth/lesion

  • staffies + boxers

  • gingival enlargement → epulis

  • benign gum growth → gingival hyperplasia during teeth

teeth,

• wear → abrasion

• fractures

• enamel defects

  • enamel hypoplasia

    • often infection as a puppy

  • resorption - crown erosion

soft tissues,

• tongue

• hard palate

• oral mucosa

  • pale, jaundice, cyanosis

• caudal oral area

• ulceration → pain → care examining

• cats prone to erosion ulcers → eosinophilic plaques

• canine removed → upper lip moves inwards → pierce lip with lower canine → can resolve in time

extra-oral

• lymph nodes

  • enlarged from gingival stomatits → poor prognostic indicators

• rest of body

  • heart & lung auscultation

  • abdominal palpation

  • temperature

  • body weight

Communication

• animals do not stop eating due to dental pain

• relate to human oral health → tooth aches

• emphasise signs of pain

• firm recommedation → discuss in detail → book follow up

Barriers for in-booking in

• GA - discuss risks

  • age is not a disease

  • benefit:risk analysis with client

  • ASA patient scale I-IV - grade riskiness

• Costs

  • may not cover dentals

  • discuss recommendations

  • discuss with clients

• Cost justifications

  • GA - anesthetic monitoring

  • recorded assessment

  • radiographs

  • nerve blocks

  • surgical extractions - oral surgery

  • scaling and polish

Antibiotics - Dentistry use

• often overuse → resistance promotion

• many/most cases not indicated

• remove bacteria manually

Appropriate use

immune-compromised patients → prophylactic use

• stress

• very old or young

• FIV+ve cat

treatment of disease

• feline gingivostomatitis

• osteomyelitis

Useful antibiotics

• amoxicillin-clavulanate → broad spec, moving away

• Narrow specs

  • metronidazole

  • clindamycin

    • bacteriostatic

    • but good bone penetration

Anasthesia and Analgesia considerations 

• other drugs 

Analgesia - multimodal before, during, after

• systemic + local options

• if in doubt assume painful

• opiods

  • methadone - 4 hrs

  • bu-pre-norphine - cats

• alpha-2 agonists - pre-meds

• local anaesthetic nerve blocks

  • lidocane

  • bu-pi-vacaine

• NSAIDS

• paracetamol - used as an adjuvant

  • when already give NSAIDS and nerve blocks post op

  • DOG only

• Opioids: bu-pre-norphine tansmucosal-cat

  • tricky, mouth painful, not easy to put on gums

• Gabapentin (preferred)

Preanaesthetic considerations

Induction of anaesthesia

• preventing hypothermia starts premedication

• check occlusion before intubation, while mouth is fully closed

• brachy - preoxygenate + warm

• extra propofal → dog

• quad → cat (4 drugs)

Count teeth

• missing PM1 in brachycephalic breeds

• unerupted tooth → risk of dentigerous cyst formation around crown

  • Fluid accumulates between the reduced enamel epithelium and the crown

• can create jaw at risk of fracture

Avoid hypothermia

• monitor and react

• cold = slow recovery → long procedure & cold water in mouth

• Methods

  • bear hugger v. effective

  • socks, bubble wrap

Avoid post-operative blindness

• not using spring-loaded mouth gags in cats

• one blood supply entering eye

• if jaw open for a long period of time

Patient positioning - under anaesthesia

• personal preference

• some prefer dentals in dorsal recumbancy

• others find it easier in lateral

Dental (surgical equiptment)

Keep comfortable - importance of posture

Health & Safety

• correct PPE

  • mask

  • apron → blood & water splashing

  • goggles

  • face shields

• bacterial aerosols

Dental radiography - usually wall mounted, could be mounted on walls

Surgical packs - sterilised

Dental unit

• high speed unit → drill normally attached (at low speed)

• polisher attached here

• often separate scaler unit

Probing and Charting

• systematic, complete assessment

• document all pathology and treatment

• medico-legal document

  • pics before and after

• client communication

• shelter level → teeth removing, what’s already missing

• periodontal pocket depth 6 places around the tooth → write colour + mm affected

Peridontal probe - blunt explorer

• cheap £15

• peridontal health - esp if no dental radiogaphy

• specific veterinary probe - groove mm

• analyse gingival sulcus depth

  • gingival sulcus - groove btw enamel + free gingiva

  • normal vs periodontal pocket Pmm

  • grooves in mm

  • deep = periodontal/gum disease indication

• check all surfaces of all teeth

• check furcation exposure

• tooth mobility → poking

Sharp Explorer probe

• probing hard dental tissues only in anaesthetised patient

• pulp exposure - in fractured tooth 

  • soft area where tooth should be

  • if enamel - sharp probe should fall off

• caries

  • sticky tooth decay

  • unusual in animals

• tooth resorption

  • blunt probe

  • sharp - better tactile feel → small holes in enamel along gum line

Modified pen grasp/pengrip

• stabilised probing

• thumb + 2nd finger → rest pinky finger on surrounding tissue → fine motor control

Gingival sulcus depth - normal

• normal cat < 1mm

• normal dog <3mm

  • focal area - leave if rest of tooth is fine

Calculus reminder

Calculus does not affect disease process

• not graded but remove to check for disease

Gingivitis grading - indicator of pathology

1. inflamed gingival margin

2. bleeding on probing

3. intense inflammation, spontaneous bleeding

Furcation exposure

1. F1: just palpable

2. F2: probe passes up to 50% width

3. F3: probe passes right through furcation

   1. air (black) instead of pulp cavity [on radiography]

   2. grade 3 → indicates tooth removal

→ multi-rooted branching

• probe from medial → lateral (into tooth)

• bone loss due to advanced gum disease

Mobility

1. M1 → <1mm horizontal

2. M2 → >1mm horizontal

3. M3 → gross mobility, vertical, + in 3 rooted tooth

Recording findings

• missing teeth/supernumerary teeth (too many)

• fractured teeth

• worn teeth

  • abrasion - 3rd body wear

  • attrition - tooth-tooth contact

• discoloured teeth

• tooth resorption

• caries - breakdown caused by acids from bacterial growth in the mouth

• signs of periodontal pocketing

  • gingivitis

  • furcation exposure

  • periodontal pocketing

  • mobility

Ultrasonic scaling

• tip vibration

  • removes calculus

  • breaks up biofilm

• heat generation

  • light touch & side of tip

    • prevents heating of tooth

• water cooling essential

• protect the airway

  • mouth gag used at some point

    • high water flying around

Scaling

• power → amplitude of vibration

• standard tips → supragingival use

• slime-line or periotips → subgingival → can go underneath gum line

Sub-gingival debridement

• slime line tip → ultrasonic scaler

• hand curettes - “root planing”

  • used if no ultrasonic scalers

• 2-5mm pockets → clear out

Polishing removes plaque and stain 

• do not write on consent form if not doing it

  • only worth it if brushing teeth at home (homecare)

• only removes plaque and biofilm

• low-speed handpiece and polishing cup

• fine prophylaxis paste

• light pressure

• short time

many stopped polishing - gone out of fashion

smooth out scratches

animals have less enamel than humans

• do not scrape off more than necessary

Locoregional anesthesia (nerve blocks)

• Pros and cons

• benefits outweigh the risk with appropriate technique

Local anaesthetic - desensitise

• cranial nerve V → trigeminal → maxillary and mandibular branches

• maxillary → infraorbital nerve block (upper arcade)

  • dog - rostrally

  • maxillary foramen → entire quadrant

  • not done in cats to close to the eye (caudal maxillary block)

  • cat - entire upper quadrant 

• mandibular → inferior alveolar nerve block (lower arcades)

  • desensitises lower arcade

  • administered - extra or intra orally

Pros

• pre-emptive analgesia (reduced nociceptive input)

• decreased GA requirement → improved cardiovascular stability

• post-operative analgesia → rapid recovery

  • 20-30 mins up and eating

  • 1-2hrs recovery with no bloks

Cons

• nerve damage if enter intraorbital

• haematoma

• local effects

  • tongue trauma

    • mandibular block in wrong place → chew because cannot view the tongue

  • globe damage

• systemic effects

  • overdose, CV side effects, death

Small Animal Dental Radiography

Parallel technique

Bisecting angle technique - imagine casting shadows into the plate

• x-ray beam too low onto flat plate - image too long

• x-ray beam too high onto flat plate - image too short

Correct height shadow

• plate flat in mouth

• angle beam to get the image

Radiography Use

• visualize root, alveolar bone, periodontal ligament, pulp

• complementary + additional probing & charting

• reach diagnosis

• select treatment

• time-saving

• client communication

• clinical profitability

• evidence based medicine

  • optional x rays hard to engage clients 

  • should be built in as part of the procedure

Not expensive for practice to use purchase

• plates reusable

Not expensive for client

Quickly profitable for client

Non-negotiable for client - good if included in dental price

Expensive set up - 10-12K

parallel technique

• tooth & sensor parallel

• x-ray beam perpendicular to both

  • x-ray target on top of plate + beam directly on top

• like limbs & body cavities

• USED:

  • cat - mandibular arcade

  • dog - caudal mandibular area

    • mandibular symphysis in way of cranial mandibular area

bisecting angle technique

• when hard palate in the way

• plate flat in the mouth

• angle the beam

• tooth & sensor form an angle

• angle bisected in half

• X-ray beam directed perpendicular to this bisecting line

Advanced imaging - CT specialist referral

• computed tomography → maxillofacial trauma cases + oncological surgical planning

• cone beam CT human dentistry

Categories of oral pathology

• Cats most common - dental disease → fractures

  Dogs most common - periodontal disease

• peridontal disease

  • supporting structures of tooth (alveolar bone, periodontal ligament, gingiva)

• endodontic disease

  • pulp - soft tissue inside the tooth

• tooth resorption

  • where tooth resorbed

• stomatitis

  • oral mucosa inflammation

• malocclusions

  • abnormal alignment of teeth and/or jaw

• maxillo-facial and dentoalveolar trauma & neoplasia

  • maxillo-facial structures

Maxillo-facial and dentoalveolar trauma & neoplasia (maxillo-facial structures)

• infection, inflammation, neoplasia

• oral/dental system - location

  • soft tissue (gingiva/mucosa)

  • bone

  • tooth

  • attachment of tooth to surrounding jaw → periodontal ligament

  • pulp-dentine disease - endodontic disease

Periodontal disease

Aetiopathogenesis

• Plaque

  • invisible film of bacteria

  • biofilm contain periodontopathogens

• Host immune response

  • genetically driven

  • inflammatory cascade

• Calculus (tartar)

  • mineralised plaque

  • rough surface → more plaque

  • not in itself pathogenic

Clinical signs

• halitosis (bad breathe)

• dental deposits - high calculus

• gingival margin inflammation

• whole if attached gingiva inflamed

• signs of periodontitis → furcation exposure + mobility

Diagnosis: probing + radiography

(horizontal & vertical bone loss)

Genetic Susceptibility 

• predisposed to develop severe periodontitis

• sometimes at a very young age

• small breed dogs + host immune response

  • Yorkshire terriers

  • Cavaliers

  • Dachshunds - prone to oronasal fistulas

  • + greyhounds

• Oriental cats

  • siamsese

  • main coon

  • british shorthairs

  • persian cats

Disease of attachment (periodontal tissues)

• infection - plaque = biofilm

• inflammation - host immune response

• gingiva → gingivitis

  • → no attachment loss

  • potentially reversible

  • extraction not necessary

  • bleeds on probing

  • normal probing depths

    • unless gingival hyperplasia

    • creates pseudopockets

  • hyperplasia → teething 11 month old cat

• PD ligament → periodontitis

  • → attachment loss (big pocket)

  • bone + periodontal ligament

  • irreversible bone loss → jaw bone loss (v or h)

  • vertical → Bone loss occurs unevenly, creating angular defects between teeth

    • Localized bone loss → v shapes btw teeth

  • horizontal → alveolar bone remains parallel. but height lost

    • even and generalized across multiple teeth

    • lowered alveolar margin level

  • Increased probing depth → periodontal pocket

    • normal cat < 1mm

    • normal dog <3mm

  • furcation exposure - blunt probe lateral→medial

  • tooth mobility

  • gingival recession

• alveolar bone

• cementum

Periodontal disease → treatment & when to refer

Local consequences

• periodontal abscess

• oronasal fistula

• pathological jaw fracture

• horizontal + vertical bone loss

• small dogs, low bone density → more common jaw fracture

Systemic consequences

• chronic bacteraemia

• increased risk of chronic kidney disease

• earlier mortality

• human associations

  • associations with diabetes

  • COPD

  • CKD

  • oral cancer

  • CV accidents

Treatment

• mechanical removal of all dental deposits above and below gingival margin

• scaling, polishing, subgingival debridement ‘root planing’

• extractions

• antibiotic use: adjunctive treament in rapidly progressive or aggressive cases

When to refer?

• always option - tailor to skill level

• high numbers of extractions per patient

• severe bone loss with high risk of mandibular fracture during extraction

  • highly eroded jaw bone → jaw fracture risk

• geriatric patients and patients of co-morbidities

  • (higher GA risk)

• mild to moderate cases - may want to save teeth

Endodontic Disease

• disease of pulp-dentine complex

• tooth fracture

• tooth wear-abrasion

• tooth trauma

  • luxations

    • tooth is displaced within its socket but still attached (at least partially) to the periodontal ligament (PDL).

  • avulsions

    • tooth is completely knocked out of its socket.

Common tooth fractures in cats

• road traffic accidents → look at teeth!

• high rise syndrome

• male cats (fighting) - usually incidental findings 

  • if couple mm missing - pulp cavity probably exposed

Concussion (pink, purple, brown tooth)

• haemorrhage into dentine → purple tooth

• protein reabsorbed → iron component stuch in dentine = grey

• often becomes necrotic

• tooth bruising - colour tinge - inflammation?

UCF - uncomplicated crown fracture

• fracture of crown DOES NOT expose the pulp

CCF - complicated crown fracture

• fracture of crown that EXPOSES the pulp

• hole in centre of tooth → use probe, can enter area

Wear - Abrasion

• tertiary dentine production if wear slow → brown stain

  • often tennis balls wear down teeth, esp canines

  • probe slips off tertiary dentine

  • sharp probe to check for pulp cavity exposure

• pulp exposure if rapid

Do not monitor

• fractured teeth → no pulp exposure requires treatment

• extractions

• OR referral for root canal therapy

Importance

• painful but do not display overt pain

• all fractures can lead to pulpitis

  • central pulp inflammed

  • due to exposure to environment

  • pulp exposure → complicated fracture → immediate infection

  • near pulp exposure (uncomplicated fracture)

Endodontic Disease - pulp necrosis

• pulp exposure - sharp probe → bleeding

• tooth discolouration - necrosis

• pulp chamber + root canal (width) → radiography

• periapical lucency → blackness around the root

  • pulp cavity - huge → increased black centre

Presentation of Endodontic disease

• usually goes unnoticed

• ONLY seen visual examination and dental radiography

• occasionally will progress severely and cause acute noticeable signs

  • draining sinuses on side of face

    • tooth root abscesses

Treatment - Extraction vs root canal therapy

Extractions

Pros

• will solve problem

• no recurrence of pain/infection in future

Cons

• invasive surgical procedure

• post-op pain

• possible post-op complications

• loses strategic tooth

  • carnasials = consider referral (specialist)

• correct skills and equipment required

Root canal therapy

Pros

• keeps strategic tooth

• less invasive

• more comfortable, immediately post-op

Cons

• referral often required

• specialist-level knowledge/skills

• expensive equipment and materials required

• success rate 70-95%

• requirement for continued monitoring throughout dog’s life

  • GA

  • costs - radiograph check ups

Stomatitis → most common in cats

• inflammation of oral mucosa

• FCGS → Feline Chronic Gingivostomatits

• CCUS → Canine Chronic Ulcerative Stomatitis

• CUPS → Chronic Ulcerative Paradental Stomatitis

Different types of mucosa in the mouth

Buccal mucosa → alveolar mucosa → attached gingiva

→ free gingiva → gingical margin

• link to FCGS terminology

  • buccal muco-sitis

  • alveolar muco-sitis

  • caudal stoma-titis

  • palato-glossitis

FCGS → Feline Chronic Gingivostomatits

• unknown aetiology: aberrant immune response to variety of oral antigens

  • associated calicivirus - often positibe PCR but not causative

  • no guaranteed outcome - frustrating + expensive to treat

  • clear client communication vital

Treatment

• antibiotics + analgesia (NSAIDS)

• total cheek-teeth extraction

  • all PM/M

  • Cs and Is if diseased

  • cures/improves 66% cats - with good QoL

  • extractions must be performed completely 

    • no root remnants 

    • confirm post op otherwise inflammation returns/keeps

• unresponsive cases → interferon, ciclosporin, steroids (last resort) → often gets worse on steroids

• stem cell therapy research in USA

CCUS → Canine Chronic Ulcerative Stomatitis

CUPS → Chronic Ulcerative Paradental Stomatitis

• oral ulceration in oral mucosa in contact with plaque-laden teeth

• inappropriate immune response

• often canines and carnassials

Treatment

• plaque control- professional cleaning/oral homecare

• extractions of adjacent teeth

[ulceration of gums in contact with calculus]

Tooth resorption

• common in cats but still possible in dogs

• cause unknown

• can be very painful - cats flinch

• radiography mandatory - impacts extraction technique

• treatment approach - extraction vs crown amputation

Clinical identification -

hard tissue loss → obscured by calculus or soft tissue loss

• tip of crown tooth

• looks like gum crown upwards to cover defect

• gum can plug enamel defects

SHARP EXPLORER: tactile feedback of enamel loss

• along gum line

• ping when hole in enamel

Radiographic identification:

• dental hard tissue loss → root lost or partially remains

• lower alveolar bone margin → horizontal bone loss 

• bile holes in the tooth - root loss (furcation exposure)

Types of tooth resorption in cats:

Type 1: defects in crown but periodontal ligament still intact

• treatment: extract if ligament intact

• type 1 - Peripheral inflammatory

  • inflammatory driven periodontal disease

  • all roots extracted

  • periodontal ligament remains intact and is visible

  • root more radio-opaque than surrounding bone

    • Radio-opaque → appearing white or light on a radiograph

Type 2: no periodontal ligament - obscured root canal → ghost roots

• treatment: crown amputation - only under radiographic control

  • lift up gingival flap either side of tooth

  • use taper fissure (dental drill) to section off crown

  • amputate crown + smooth out with diamond bur

  • suture flap (stitch gum flaps back together)

• type 2 - replacement

  • iodiopathic

  • periodontal ligament - lost as tooth root absorbed + eventually replaced by alveolar bone

  • root has same radiodensity as surrounding bone

    • fuzzy appearance

    • no defined periodontal ligament

Both types can occur in same cat and same tooth

Type 3 - combination of both - often no tooth present

• different root - often lower M in cats 09

• no root in one (smaller distal root), periodontal ligament in other (chunky mesial root)

Removing roots - dos and donts

NEVER - drilling out roots/atomisation

• drill around root - never directly on root

• will not remove root

• malpractice

• completely inappropriate procedure

• iatrogenic trauma

• potentially fata;

What if root cannot be removed (GP level)

• choose to stop if further trauma could occur

• tell clinet

• close up + document in client records

• monitor radiographically - might resorb - if a cat

• offer referral - some root fractures during removals

Malocclusions

Different classes I-IV + tooth on soft tissue contact  + tooth on tooth contact (attrition)

• often removal of 1 tooth can cause issues with others

  • deciduous canines - poke into hard palate or soft tissues

  • young dogs head shy - behavioural signs → painful, distressing

• normal occlusion is tight

Definition

• inappropriate position of teeth and jaws or both

• treat PAIN

• treat DYSFUNCTION

Class I

• normal rostrocaudal relationship of maxillary and mandibular dental arches

• with malposition of one or more individual teeth

  • base narrow canines → GSD puppies

  • narrower mandibular arcade - remove deciduous canines

  • lower canine teeth angle inward + press into roof of mouth → damage gum tissue + palate

Class II

• maxillary arcade longer than mandibular arcade

  • abnormal rostrocaudal relationship btw dental arches

  • mandibular arch occludes distal to normal position relative to maxillary arch

Class III

• mandibular arcade longer than maxillary arcade 

• expected in some brachy breeds

  • abnormal rostrocaudal relationship btw dental arches

• mandibular arch occludes mesial to normal position relative to maxillary arch

Class IV

• asymmetry btw mandible & maxilla

  • maxillomandibular asymmetry

Tooth on Soft Tissue Contact → painful

• severe cases causes oronasal fistulas → canines pierce into nasal cavity

  • mandibular canines pierce soft tissues

• abnormal opening between oral & nasal passages

• observe + investigate before ET tube inserted

Malocclusions

• causes

• treatment options

• paediatric malocclusions

Causes

• history of trauma

• genetic 9/10

  • do not breed from affected animals

  • recommend neutering - cannot enforce

Treatment Options

• extractions

  • quick in puppies → early 12 weeks

  • gives more room for adult canones to grwo in correct place 

  • discuss advanced practitioner/specialist

• orthodontics → referral (braces, buttons, chains)

• crown shortening & vital pulp therapy → referral

  • cap over pulp - prevent exposure to outside environment

Paediatric Malocclusions

• pain  - pick up early at vaccination appointments

• interference with jaw growth

  • extractions → refer

  • iatrogenic damage to permanent tooth buds

    • have to extract tooth buds as well if procedure foes the wrong way

Maxillofacial trauma repair

• initial treatment and repair

Initial Treatment

• triage, stabilise

• 70% maxillofacial fractures have dental fractures

• traumatic fracture

• vs pathologic fracture → through an area weakened by disease, often with minimal or no trauma

• refer for repair

  • repairs → focus on accurate restoration of occlusion

Repair

• noninvasive support → done during a dental procedure

• wire and acrylic

• maxillomandibular fixation

  • tape muzzle/mickey muzzle

  • then ask for referral advice

Oral masses

• odontogenic tumours

  • remnants of odontogenic epithelium (e.g. dental lamina, enamel organ, Hertwig’s root sheath)

  • Or from ectomesenchyme (e.g. dental papilla or follicle)

• non-odontogenic tumours

  • bone, cartilage, blood vessels, nerves, or soft tissue

• benign vs malignant

• dental radiography

• incisional biospy

• CT for surgical planning → refer

  • removing parts of jaw

  • dog → do well

  • cat → less so

Dental Extractions - Closed

General info

• high-speed handpiece (dental drill)

  • btw thumb & index finger

  • support index finger with second finger

• fingers placed, not curled behind

• fine motor control

Closed Extraction

• section tooth of necessary - depends on root number

• use hand instruments to deliver tooth

  • luxators, elevators

  • break down periodontal ligament

• suture socket or heal by second intention?

• healing by granulation or primary intention

  • suture = 1st intention

Pros

• simple

• good starting point

• can be quicker especially for simple extractions

• suitable or certain single-rooted teeth - not canines

Cons

• extraction sites may impact with debris and lose blood clot

• increased risk of breaking roots

• slow & difficult for complicated extractions - not ideal method

• healing slower - often by second intention

Dental Extractions - Open

Open Extraction (surgical)

• mucogingival flap - created

• removal of some buccal bone from overlying tooth

• use hand instruments to deliver/remove tooth

  • periodontal disease → ligament broken down already

  • not much required to remove the tooth

• smoothing of bone - alveoloplasty - encourage some gum healing

• suturing flap tension-free 

• healing by primary intention

Pros

• quicker more predictable healing → primary intention

• prevents impaction of extraction site with debris

• can be lifesaving

• makes difficult extractions easier

  • some teeth impossible without an open approach

    • difficult extractions

      • long rooted

      • resorbative lesions

      • fragile roots → cats

Cons

• more time consuming

• risk of flap breakdown if not executed well

  • Aim for gum flap to be returned under no tension

• technically more difficult - but simple set of skills to learn

Follow up of Tooth extractions

Anaesthetic recovery

• pain score → analgesic plan → opioids post precedure

  • Grimace → scale better than mouth poking

• should be ready to eat soon → eat 30 mins when comes round

Discharge appointment with client

• clean up blood

• explain treatments to clients, show dental chart, radiographs, explain imminent post op care

• leave long term planning and care to follow up late

• 3-4 day post-op check → extraction sites healing, GA recovery

• 7-10 days [week later] → start toothbrushing

  • check up on extraction sites - healing

• 3 months → about homecare → nurse appoitments

Oral Homecare

• toothbrushing - brush and paste

• diet + dental chews

• Toys

Getting clients into good oral health habits - starts with puppies and kittens

Daily plaque control - plaque off? (type of biofilm)

• if too good to be true then probably is

Toothbrushing - brush and paste

• start aged 6 months

• pet toothpaste

• routine/praise/reward

Brush → soft/medium bristle brush

• pet or human

• finger brushes as intro only - CARE

Paste → pet specific, enjoyable, brush on

Diet + Dental chews

• dental specific ones available

  • specific textural characteristics of dental diet

  • some evidence diet brushes tooth as animal eats

• wet food does not cause periodontal disease

• dry food not protective

Chews

• look for published evidence

• plaque and calculus control

  • calorie reduction in diet to balance → chews have calories 

  • not all chews created equally

  • how quick do they eat

• consider feline tooth function

Toys

• AVOID bones, antlers, plastic toys, pig ears

• risk of crown fracture

• tennis balls and other abrasive toys must be avoided

• bin if u cannot bend

• bones → crown fractures PM04 → slap fracture

  • chunk breaks off