Is it acceptable to "have a go"?

Re: Is it acceptable to "have a go"?

James Laidlaw — Fri, 22 Jun 2012 14:19:06 GMT

I remember someone talking to us pre-graduation who said:

"When you get out of university and into your fist job, you will know a little bit about a wide range of topics, however, most clients who come in will expect you to know EVERYTHING about their specific problem."

No-one knows everything about everything and that's fine. It's fine to have a go at things provided the complications aren't catastrophic (eg: I'd never attempt "have-a-go" spinal surgery...) and it's the only way to build your skills and knowledge base. No-one wants to be stuck doing vaccinations and neuterings for the rest of their career, do they?

Re: Is it acceptable to "have a go"?

Jo Cobbett — Thu, 21 Jun 2012 12:12:46 GMT

[quote user="Martin Atkinson"]

[quote user="KMurphy"]I feel like I've given the impression now that I'm a sort of bumbling idiot, making silly decisions at every turn! Sorry if this is how it has come across. I'm a cautious surgeon but I'm generally okay at my work and usually manage just fine. It's just sometimes I wish there were someone else in the practice with whom I coud discuss cases like this that are a bit out of my comfort zone.[/quote] Don't blame yourself Kate, this is the result of the litigious society and the veterinary schools putting the fear of God into you that you will be hauled up in front of the RCVS at every turn, I'm sure there is very skilful, confident clinician fighting to get out of a conservative shell. I have the same issue with a recent graduate who even one year on turns from a knowledgeable young vet who can hold her own in any clinical discussion into a frozen, panic stricken, dithering bag of nerves at the first sign of anything she is unfamiliar with. I don't know what the cure is, I've tried everything from talking her through procedures step by step while saying things like, 'don't worry you're doing just fine everything will come with experience', to 'for Gods sake get a grip', but one year on things are barely improving and she is very frustrated because she knows this herself. I don't recall a day when I wasn't super-confident about everything and would have a go at whatever was put in front of me but even I have learned to accept my limitations. In the end only you can decide if you're going to proceed with something you're not happy with or accept your own limitations but you are missing an exciting world with far more moments of the euphoria of supreme satisfaction of success than regrets of failure by not having a go.

[/quote]

when I was about 18months/2 years qualified when I realised that it was OK not to know everything. Up until then anything I was unfamiliar with/unsure of would send me into a private panic and make me feel I was a hopeless vet, but then I realised that I didn't need to be able to diagnose everything on the spot, I could run tests/discuss with colleagues/consult text books (and Vetsurgeon forum of course!) to reach my diagnosis. And I became much more confident as a result, able to discuss what I did know about their animals with clients, and discuss with them what else I would do to find out what I didn't know. It possibly helped that I moved to a very supportive practice just over a year after I qualified, with experienced vets who have been great mentors. At my first job there was just the boss (who was frequently absent, or otherwise shut up in the office) and three vets who were all less than three years graduated, so we were all helping each other.

Re: Is it acceptable to "have a go"?

Hannah Wynne Richards — Thu, 21 Jun 2012 10:01:01 GMT

I think some academics have a nasty habit of sneering at practitioners when they're discussing cases with studets-and the insiduous drip drip drip effect of this is to make those who go into general practice feel inferior from the start

I'mfar from being an expert dentist but I've never found puppy canines difficult to extract -fiddly -yes-difficult-no

Wynne

Re: Is it acceptable to "have a go"?

Martin Atkinson — Thu, 21 Jun 2012 09:49:33 GMT

Re: Is it acceptable to "have a go"?

KMurphy — Wed, 20 Jun 2012 13:21:59 GMT

[quote user="Evelyn Barbour-Hill"] As for the idea of extraction, that would be pointless, insane. [/quote]

Don't worry - I wouldn't be rushing into anything as insane as that!

I feel like I've given the impression now that I'm a sort of bumbling idiot, making silly decisions at every turn! Sorry if this is how it has come across. I'm a cautious surgeon but I'm generally okay at my work and usually manage just fine. It's just sometimes I wish there were someone else in the practice with whom I coud discuss cases like this that are a bit out of my comfort zone.

I guess that's where VetSurgeon.org comes in...

Re: Is it acceptable to "have a go"?

Evelyn Barbour-Hill — Wed, 20 Jun 2012 12:54:49 GMT

Lots of American authors there publicising the original discovery by Leen Verhaert (a Belgian veterinary surgeon).

The picture in Alet's link gives you the idea - the size of ball needs to be approximately suited to size of dog.

As an aside: that stupid American term "base narrow canines" drives me mad!

I've never tried the "temporary wedge" and I'm not inclined to. Shoving a foreign body in the periodontal ligament does not seem a good idea, even if it "seldom causes any problems".

Finally: if one or both canines ends up lingually displaced, then while orthodontic movement is straightforward and may be the choice in some situations, crown shortening (often by only a few millimetres) is often all that is necessary. As for the idea of extraction, that would be pointless, insane.

Re: Is it acceptable to "have a go"?

Alet Engelbrecht — Wed, 20 Jun 2012 09:56:09 GMT

Also managed to find this in the proceedings of 2003 World Vet Dental Congress, lecture given by Heidi Lobprise - looked interesting.

When it is first apparent that the mandibular canines appear to be erupting base narrow, owners can sometimes help by applying regular digital pressure outward on the erupting canine, or even use a hard rubber ball (eg, raquetball) to help splay the teeth out. If the tip of the tooth barely
hits the gingival margin of the palate, a gingivoplasty procedure may be sufficient to provide release for the tooth.
Teeth that are slightly more medial may benefit from a composite restorative extension placed on the tip of the tooth that acts as a type of incline plane to get the tooth to slide out laterally, while at the same time releasing the point of contact with the palate (camoflage orthodontics).
If retained deciduous teeth are present, after their extraction, a portion of the root (rinse in sterile saline) may be gently placed in the periodontal ligament space medial (lingual) to the base narrow tooth, to help push it labially.
This temporary wedge seldom causes any problems, and is often lost with additional eruption of the mandibular canine. If these simple methods fail to work, a maxillary incline plane (usually bilateral) will need to be placed after full eruption to move the teeth into a more comfortable position, to avoid crown amputation or extraction.

Maybe you can try this temporary wedge in the next case! Sounds scary to me, I think I'll leave it to Evelyn or Cedric...

Re: Is it acceptable to "have a go"?

Alet Engelbrecht — Wed, 20 Jun 2012 09:38:56 GMT

[quote user="KMurphy"]Stupid question of the day - what do you do with it? Just let them play with it as normal? Or encourage them to hold onto it with a tug-of-war type game?[/quote]

See this link with images to describe ball/kong therapy - don't know how to make it into a link, so just copy & paste into browser.

http://www.toothvet.ca/PDFfiles/ball_%20therapy.pdf

EDIT: Managed to do it, hopefully will work now!

Ps - I was thinking of this thread today when I had to extract my own 7m old kitten's retained deciduous canines - only ever saw a handful in cats, and sod's law in my own!

Re: Is it acceptable to "have a go"?

KMurphy — Wed, 20 Jun 2012 09:11:43 GMT

[quote user="James Laidlaw"]Kong cone toy for when the adult teeth come through 15 min 3x a day can make a massive difference to their position shifting to normal[/quote]

Stupid question of the day - what do you do with it? Just let them play with it as normal? Or encourage them to hold onto it with a tug-of-war type game?

Re: Is it acceptable to "have a go"?

Mark Hedberg — Wed, 20 Jun 2012 08:49:36 GMT

Honestly, just reading some of Evelyn's descriptions helped my dentistry technique no end - do a search in the forums, really good stuff in there. Go write a book, Mr Barbour-Hill!!! :D

Re: Is it acceptable to "have a go"?

James Laidlaw — Tue, 19 Jun 2012 21:31:04 GMT

They're only fragile if you force them. Book plenty of time and don't rush. Kong cone toy for when the adult teeth come through 15 min 3x a day can make a massive difference to their position shifting to normal. Worked well in a Westie I saw this year that had the same type of problem and extractions at 12 weeks old.

Re: Is it acceptable to "have a go"?

KMurphy — Tue, 19 Jun 2012 21:25:41 GMT

Hi Evelyn,

Thanks very much for the information and the description of the procedure - I shall print it and keep it near when I'm doing the procedure. It was the open technique that I had intended to do anyway.

In this case there is already trauma to the hard palate - the deciduous teeth are significantly displaced so I really do think that extraction is necessary to at least give the permanent teeth any chance of coming through in a normal position. There aren't any other bite defects that I can see.

I'm a one-person practice in Scotland, in a semi-rural location. There are other small animal practices about but none that I know of personally that would be any better placed to do the procedure. I took over the practice a few years ago and the dental equipment was very basic (some hand instruments only) but, after muddling along with a Satelec cocoon for a couple of years, I now have a new im3 machine and have just ordered new sharp luxators, which I've been meaning to buy for ages anyway. I know it may not sound like it, but I can competently extract teeth, including canine teeth. It's just the fragility of the deciduous teeth that has me a bit nervous and the size of the flaps that I have to create! I would happily sew a dog back together if it were presented to me in pieces and there's not much soft tissue surgery that I would find too daunting but for some reason dental work makes my blood run cold.

I really appreciate all the input from everyone - thank you.

Re: Is it acceptable to "have a go"?

Rajat — Tue, 19 Jun 2012 20:38:21 GMT

Thanks guys, we use Roots routinely for dental servicing etc so familiar with them. Will give them a bell tomorrow.

Have to say, the Eva dental sensor they sold us was not very impressive though, especially after it 'broke' after 18 months!

Cheers

Raj

Re: Is it acceptable to "have a go"?

Evelyn Barbour-Hill — Tue, 19 Jun 2012 20:13:10 GMT

[quote user="Michael Woodhouse"]As do Roots Dental (google them)[/quote]

It's worth supporting Roots because they do actually know about what they are selling..

Re: Is it acceptable to "have a go"?

Michael Woodhouse — Tue, 19 Jun 2012 19:58:53 GMT

[quote user="Rajat"]Thanks for the description Evelyn, I must get some of those Fahrenkrug elevators.. do you know of a UK supplier for them? [/quote]

Vet-Direct list them

http://www.vet-direct.com/default.php?sid=VD-5196-6637-3918&sessiontag=prodfullview&data=1830

As do Roots Dental (google them)

Re: Is it acceptable to "have a go"?

Rajat — Tue, 19 Jun 2012 19:47:58 GMT

Thanks for the description Evelyn, I must get some of those Fahrenkrug elevators.. do you know of a UK supplier for them?

I love my Directa dental luxators, and second the vote for sharp luxators. Sharp steel is a joy to use. We are lucky to have a sharpening machine, the Rx Hone, which will sharpen (and destroy if adequate care isn't taken!) luxators very quickly and efficiently.

I have to admit I have done a flap on occasion when the root has snapped on me to prevent 'digging' and damaging the permanent tooth bud. At all other times a closed extraction as others have advised. I also use a fine 21-23 gauge needle as my initial luxator to tear the fibres close to the gingiva. I prefer this to a #11 blade. One can be quite 'enthusiastic' with the needle as opposed to a luxator.

Unless significant oral pain + ulceration is present, I'd suspect 3mo is too young for this procedure - best to wait and see if there is a prob like Evelyn described with the permanent dentition.

Raj

Re: Is it acceptable to "have a go"?

Evelyn Barbour-Hill — Tue, 19 Jun 2012 19:04:24 GMT

With regard to the principle, what Michael and Malcolm said.

With regard to this particular case in general, it's a classic example of why "referral" does not automatically imply "expensive".

[quote user="KMurphy"]There's no local practice that I know of that has a dental enthusiast so passing the buck isn't really an option either.[/quote]

There's no reasonably local small-animal practice?

Anyway, to the details of this particular case. Can we get it clear what you are dealing with? As i read it, it seems you have a pup with all its deciduous dentition, and the deciduous mandibular canines are lingually displaced. Is this right? If that's the situation, then hang on a minute. You may not need to do anything at all at this point.

(Incidentally, did you suggest extraction, or did the owner come in demanding it?)

Are the offending teeth seriously traumatising the soft tissue of the palate? Is eating or comfort affected? If not, don't do anything. These teeth will be shed at the usual time anyway. Yes, the permanent canines will probably be lingually displaced too, but that's not because the deciduous precursors were lingually displaced.

By the way, is the occlusion normal otherwise? Both brachygnathism and prognathism are among the causes of lingual displacement of the canines.

On the other hand, if what you have is a dog with "retained" deciduous canines and the permanent canines coming through lingually (12 weeks sounds awfully young for this), then you do want to extract the "retained" deciduous teeth. There are various reasons for extracting them, but it is very debatable whether the retained deciduous are displacing the permanent or whether in fact the deciduous are retained because the permanents are coming up too lingual. Personally I am firmly of the opinion that the latter is the case, but breeders will never believe me.

What I'm getting at is that you should not tell the owner that what you are doing will prevent the permanents from being displaced, because they are likely to be disappointed!

So, if you are sure it needs doing, what about extracting these deciduous canines? There are two possible methods, but you do not need power instruments for either of them. However you do need suitably sized, good quality properly sharp instruments, (and I am guessing that your practice does not actually possess such things.)

Next, bear in mind the anatomy of the teeth concerned. The crowns are very curved but the roots are practically straight and longer than you would ever have guessed. They run quite close to horizontally.

Now, whichever method you choose, make sure there are no forceps even in the same room as yourself. You must eschew forceps and loosen the tooth entirely with luxators until it is so loose you can pull it with your fingers.

The "closed" method - which I do not recommend for you - is to keep working suitable luxators down evey aspect of the root that you can (being extremely careful to stay parallel to the root, especially on the medial side; as you make progress you can twist the instrument ever so slightly; the fine Fahrenkrug elevator can help on the curved aspects; until the tooth is loose enough to extract with your fingers. If it won't quite come, then rapid pushing and pulling, as if pumping it, will break down remaing fibres.

The tyro or reluctant dentist should use the "open" method, every time. It is very easy. There are diagrams in books. You make a longitudinal incision dorsal to the tooth, then a short vertical one by the crown, and elevate (with a periosteal elevator) the resultant triangle of mucoperiostem from the bone (this is the mucoperiosteal flap). Then you pass your fine sharp luxator or elevator down the lateral side only of the tooth, and actually break and flick off the bone from this side of the tooth. The bone is very thin and soft. You don't need to go right to the apex, just as near as you reasonably can. Then you lever (very gently, almost no force at all) the tooth out sideways by passing a fine luxator down the medial side. Then you suture the flap back where it came from with something fine and absorbable (5/0 or 6/0, Vicryl or Monocryl for instance.) You could use 6/0 Ethilon or something, but then the sutures might need to be removed.

That looks far far more complicated in words than it really is.

And if you would still rather not do it – whereabouts are you?

Then of course later on you'll probably have those lingually displaced permanent teeth to deal with. Call again at that time

Re: Is it acceptable to "have a go"?

KMurphy — Tue, 19 Jun 2012 18:09:47 GMT

[quote user="Niall Taylor"]Not quite clear here - do you mean the deciduous canines are retained and have displaced the permanents medially?[/quote]

No, the deciduous canine teeth are positioned in too far a lingual position so that when the dog closes its mouth, the lower canine tooth is essentially digging into the hard palate. Apparently, the permanent teeth usually erupt lingual to the deciduous teeth, so removing the deciduous teeth is the only option to allow some more room for the permanent teeth to erupt in a normal position.

I usually refer to DentalVets in North Berwick, who have a great website and good information on this and have been more than helpful with the cases I've sent them. I've seen quite a few cases of this recently - this is the first one I'll have to do anything with thanks to the four week free cover that most pups come with now :) Poodles and Labradoodles (I hate that word!!) seem to be the main culprits. I've also had one Yorkie with the condition and the dental referral practice said that Spinones seem to be commonly affected also.

Re: Is it acceptable to "have a go"?

Malcolm Ness — Tue, 19 Jun 2012 17:25:25 GMT

[quote user="KMurphy"]It's just every time I try to be nice lately it comes back to bite me on the backside! [/quote]

You are not alone there!

Re: Is it acceptable to "have a go"?

Hannah Wynne Richards — Tue, 19 Jun 2012 16:21:44 GMT

I'm with James If people don't want tospend they'll often try to get out of paying anything at all if they can-by blaming the veterinary surgeon-so get written dated consent if you leave anything out

Wynne

Re: Is it acceptable to "have a go"?

Niall Taylor — Tue, 19 Jun 2012 16:10:46 GMT

[quote user="KMurphy"]Lingually displaced canines in a 12 week old pup[/quote]

Not quite clear here - do you mean the deciduous canines are retained and have displaced the permanents medially?

Niall

Re: Is it acceptable to "have a go"?

James Laidlaw — Tue, 19 Jun 2012 14:55:54 GMT

I've done them that way too Martin, and agree with you, BUT, when money is an issue and you're trying to be nice I've found people complain more. If you have skipped steps then you need the client to consent to this too, cause if anything goes wrong then you're responsible.

Re: Is it acceptable to "have a go"?

Martin Atkinson — Tue, 19 Jun 2012 14:15:52 GMT

[quote user="James Laidlaw"]You need a slow speed drill to access the tooth under a gum flap, and fine elevators. Patience is key. Also you really need pre extraction x-rays to assess the location of the tooth and it's adult version relative to each other.[/quote] Sorry James but this sounds like overkill given there is also a money issue here and making it sound scary to someone who is not too confident anyway. I've removed myriads of deciduous canines over the years and all I've done is gently work my way down the root of the tooth with a fine elevator keeping the point firmly against the tooth all the way avoiding too much leverage and when it is loose then apply some gentle twisting action and traction and out they pop. It needs a little patience but I've never damaged a permanent tooth yet.

Re: Is it acceptable to "have a go"?

Alet Engelbrecht — Tue, 19 Jun 2012 13:12:47 GMT

[quote user="James Laidlaw"]Also you really need pre extraction x-rays to assess the location of the tooth and it's adult version relative to each other.[/quote]

Yes, in an ideal world, but if you don't - still get on with it. Even if you damage the permanent bud - mostly you will see brown enamel defects in the permanent and I have seen some that were done by very competent colleagues and still have enamel defects - so can happen to the best of us.

I would also suggest some rubber ball/kong therapy to help with jaw development, starting as soon as you can after extraction. Also, suture the extraction sites, have been told it just buys you some more time for the jaw to develop and allow better placement for the canines.

Good luck - not that difficult. If you can properly extract feline teeth with resorptive lesions, this is a piece of cake.

Re: Is it acceptable to "have a go"?

James Laidlaw — Tue, 19 Jun 2012 12:59:31 GMT

Agree to wait for Evelyn, but they aren't too difficult provided you have the equipment, and the patience to not try and rush!!!

Don't put instruments between the deciduous and permanent tooth (permanent is usually rostral to the deciduous) as you will damage the emerging adult tooth, but this is a potential problem even if you are very careful as I understand it. You need a slow speed drill to access the tooth under a gum flap, and fine elevators. Patience is key. Also you really need pre extraction x-rays to assess the location of the tooth and it's adult version relative to each other.