Replacing avulsed teeth

Re: Replacing avulsed teeth

J G Wray — Sun, 30 Dec 2012 17:58:43 GMT

[quote user="Evelyn Barbour-Hill"]That crack has just put another fiver on your bill [/quote]

Anecdote

A few years ago I received a call from a carer, someone a client had left in charge of their Labrador whilst away. The dog had been bouncing next to her when washing up and had snaffled a Brillo pad from the draining board.

The radiograph was a marvel of contrast given the metal mesh and soap with which Brillo pads are impregnated.

During the gastrotomy, the normally garrulous nurse assisting me was strangely quiet, pensive in fact.

I asked her what was up

"Well," she said "Do you think we could put more than a bit extra on this bill?"

"Why?" I enquired

"You know who owns this dog, don't you?"

"No"

"He's my gynaecologist"

"And....?"

"He didn't warm the spoons last time I saw him"

JGW

Re: Replacing avulsed teeth

Evelyn Barbour-Hill — Sun, 30 Dec 2012 16:40:52 GMT

[quote user="Pynadath George"]Well we need to clawback some of the money lost when we attend a vet! ;)[/quote]

That crack has just put another fiver on your bill

Re: Replacing avulsed teeth

Pynadath George — Sun, 30 Dec 2012 08:15:37 GMT

[quote user="Michael Woodhouse"]

[quote user="Evelyn Barbour-Hill"]Human dentistry considering not keeping a tooth? Wow. There's a new departure.[/quote]

[it's a money making ploy - have you seen how much human dentists charge for implants? . No, sir, you don't want your old tooth back - can give loads of problems, you see, give it a few weeks and I'll fit you a new one.............]

[/quote] Well we need to clawback some of the money lost when we attend a vet! ;)

Re: Replacing avulsed teeth

Michael Woodhouse — Sun, 30 Dec 2012 00:20:03 GMT

[quote user="Evelyn Barbour-Hill"]Human dentistry considering not keeping a tooth? Wow. There's a new departure.[/quote]

Re: Replacing avulsed teeth

Evelyn Barbour-Hill — Sat, 29 Dec 2012 21:51:11 GMT

[quote user="Pynadath George"] In human dentistry we wouldn't wait till the periodontium has healed. We would start endodontic treatment generally 7 -14 days after the trauma. Allows sufficient acute inflammation from the trauma to settle down. But the periodontium ISN'T stabile at this point. We start the endo as its likely that there won't be any periapical infection at this point. Improving endo prognosis. The tooth won't be generally mobile as it will be splinted while doing the endo. The point you mention that theres no point worrying about tge endo until the periodontium heals; well the periodontium may not heal if the endodontic state of the tooth is not addressed (endo-perio infection).[/quote]

Ye-es. That's interesting. At least we agree that you have to think about the pulp and that you don't start mucking about with the pulp straight away. We may need to agree to differ about timing, or at least ascribe our differences to species differences including various subordinate factors such as owner perception, owner preference, costs, necessity of salvaging tooth, practicality of salvaging tooth, and so on and so on.

[quote user="Pynadath George"] I wasn't questioning why you would do a full rct. This is appropriate is most cases. I was trying to put across that a full rct may not be needed in ALL cases.[/quote]

Well, that's how it came across. Never mind. You will have to take my word for it that pulp survival is vanishingly unlikely. Now I come to think of it, I don't think I have ever seen an avulsed, but otherwise undamaged, tooth in a dog or cat young enough to have an open apex. I'm speculating that maybe in a dog so young the common sorts of forces which would avulse an older dog's tooth would break or shatter or mangle that of the younger dog with its much thinner dentine.

[quote user="Pynadath George"] or leave the tooth out. I can't imagine it would cause psychological issues or a loss in function losing a tooth for a animal.[/quote]

Well, yes, that's what Michael was saying and probably others are thinking. It's a fair point of view. My feeling is that if you can replace the tooth without excessive measures, and its condition suggests a good prognosis, and it's a tooth of sufficient proportional importance, then why not do it? If it fails you can extract it later.

Function? Well, losing a tooth for a horse or a rabbit can be pretty significant............. sorry, that was uncalled for, I know you were referring to cats and dogs. Sure, I have many toothless cats among my patients and I sometimes think they are the healthiest of the lot..... they don't kill many mice and they have a little difficulty grooming themselves. Dogs............ without any upper 8s or lower 9s they can't manage biscuits or chews too well. Without the 4s - well, without the 4s and the upper 3s really, as they form a unified mechanism - they have to adjust their lives and they definitely look Toothless. I have on the go right now a Saluki cross from which for periodontal reasons I extracted every single tooth, except the 4s and the upper 3s which I think it worth going to some lengths to preserve.

Slightly mischievous PS : I wouldn't give a course of antibiotic at all after replacing a tooth. Chlorhexidine-based mouth rinse, that's all.

Very mischievous PPS:

[quote user="Pynadath George"]So why reimplant? In humans we are considering this too due to the problems of ankylosed teeth.[/quote]

Human dentistry considering not keeping a tooth? Wow. There's a new departure.

Re: Replacing avulsed teeth

Pynadath George — Sat, 29 Dec 2012 20:24:24 GMT

So from my understanding of things. Due to the limited use of vitality testing. If this is a mature tooth, I would start rct as soon as possible (7-14 days) after splinting tooth or at time of reimplantation or leave the tooth out. I can't imagine it would cause psychological issues or a loss in function losing a tooth for a animal. So why reimplant? In humans we are considering this too due to the problems of ankylosed teeth. The chances and risks may outweigh the benefits.

Re: Replacing avulsed teeth

Pynadath George — Sat, 29 Dec 2012 20:15:35 GMT

Couple of points here to discuss. In human dentistry we wouldn't wait till the periodontium has healed. We would start endodontic treatment generally 7 -14 days after the trauma. Allows sufficient acute inflammation from the trauma to settle down. But the periodontium ISN'T stabile at this point. We start the endo as its likely that there won't be any periapical infection at this point. Improving endo prognosis. The tooth won't be generally mobile as it will be splinted while doing the endo. The point you mention that theres no point worrying about tge endo until the periodontium heals; well the periodontium may not heal if the endodontic state of the tooth is not addressed (endo-perio infection).This is according to the current guidelines within sports dentistry, paediatric dentistry and endodontic dentistry. The text book you mention (if human dentistry) maybe out if date? On the other point. I wasn't questioning why you would do a full rct. This is appropriate is most cases. I was trying to put across that a full rct may not be needed in ALL cases. If the apex was closed or partially closed in a mature tooth an rct is indicated 7-10 days after treatment for human dentistry. The only time we assess differently is if there's an open apex. In these cases it's recommended not to as there's a good possibility of pulp survival.

Re: Replacing avulsed teeth

Evelyn Barbour-Hill — Sat, 29 Dec 2012 19:22:54 GMT

[quote user="Pynadath George"][quote user="Evelyn Barbour-Hill"]

You will need to address the question of the pulp sooner or later, whether you elect to do a full pulp extirpation once the periodontium is sound,.

[/quote] why would you do a full extirpation of the nerve unless it's damaged. The periodontium being sound or not is irrelevant surely, even in veterinary cases? Full extirpation is indicated depending on apex (closed or open) and vitality testing of the nerve with signs and symptoms.[/quote]

Good point.

Firstly, I was just pointing out that the discussion to that point had only been concerned with the periodontium (the immediate problem) and that the pulp had to be considered too.

I said, "once the periodontium is sound" because, in this context anyway, there would be no point in worrying about the endodontic state if the periodontium failed to heal! The tooth would have to be extracted. Also, because worrying about the endodontic state can wait until the tooth is solid in the periodontium again, and I for one would not care to do any sort of endodontic treatment in a tooth wobbling around in an unsound attachment! This is also the conventional textbook attitude - basically summed up as "get the tooth implanted again with as little faffing about and interference as possible - endodontics can wait". I guess textbooks can become out of date, but it makes good sense to me. My journal reading does not tell me anything different. One sees case reports in man where things were done differently, but only in rather special cases.

Sure, to do things "properly", such cases as in the original post would have radiographs, repeated radiographs, assessments, etc etc, and I would be doing all that, but in the context of the OP none of that would be absolutely essential. There would always be a degree of bone fracture (unless the tooth had advanced support loss already, which would be a different matter altogether - not much point in trying to salvage that one) and I would assume that the OP would have sufficient professional nous to have his suspicions aroused if there were any more serious fracture.

Why would I do a full root canal procedure, if I did? Because in the dog or cat when teeth are avulsed in the manner described it can be guaranteed that the pulpal blood supply has been severed and it is desperately unlikely that the pulp could possibly survive. Maybe it has done in some cases? I'd be interested to hear of them. You have a choice: either do a full RCT as soon as the periodontium is sound, pre-emptively as it were, or keep monitoring and proceed to RCT when you see periapical lucency or when there are symptoms or even signs of tooth pain (which can be very hard to be certain about - finding pain is pretty definite, but not finding pain does not mean the dog does not have toothache.) Either approach would be perfectly fair and the choice would depend partly on informed owner preferences.

Vitality testing has its uses, but it is not in the veterinary field extremely useful. It can be quite hard to do with both accuracy and humanity in cat or dog, and it doesn't tell you everything. A tooth with pulpitis will be "vital" but a full RCT quite likely still indicated (I admit that example is not very relevant to the avulsion discussion)

The OP did not mention the ages of the dogs, but from the context I doubt very much that either had open apices.

Re: Replacing avulsed teeth

Pynadath George — Sat, 29 Dec 2012 15:00:00 GMT

[quote user="Evelyn Barbour-Hill"]

You will need to address the question of the pulp sooner or later, whether you elect to do a full pulp extirpation once the periodontium is sound,.

Re: Replacing avulsed teeth

Pynadath George — Sat, 29 Dec 2012 14:56:15 GMT

Prognosis for the pulp is good if it's a immature tooth. Even if it isn't you can root treat or extract. It's the periodontal ligament which you need to worry about. If the tooth becomes ankylosed then it's a problem.

Re: Replacing avulsed teeth

Pynadath George — Sat, 29 Dec 2012 14:50:48 GMT

[quote user="James Laidlaw"]

I think the dentists would normally have some radiographs to assess the roots and the surrounding teeth and probably some wire or bonding material to help anchor the teeth in place until they take. No doubt one of them will pop along and opine soon enough! Good luck!

[/quote] Well here I go.... Yep it was probably a good thing that the tooth was still in the mouth. If it did come out for humans we would advise to keep it in the cheek sulcus or milk as a poor second. If its touched the floor it really needs cleaning first in saline. Touch the coronal part of the tooth only. Avoid touching the root. Make sure you see if the apex of the tooth is closed or open and the tooth is intact. Reimplantation normally is done with a bonded wire splint of some kind to be left on for approx 2 weeks. Check the alveolar socket. If the is bone fracture it should be removed or splinted or repositioned depending on size. Weeks worth of antibiotics is given. Soft food and soft tooth brushing for 2 weeks is advised. Pax ray is taken. Sutures are only done if lacerations are present. After 2 weeks peri apical X-ray is taken again and the toothsome vitality is checked.the splint is also removed. If normal response to vitality the tooth would be monitored over 1 mo, 3 mo, 6 mo, 1 year. If poor vitality response endodontic treatment is performed. In reality it's not the endodontics which is a problem later on. If you can't do the Endo I would imagine in a animal you can just extract the tooth. The real problem is ankylosis of the tooth. This has a higher chance from occurring if the tooth has been out of the socket for more than 1 hour. If anyone has treated a ankylosed tooth, you know what I mean by nightmare!!

Re: Replacing avulsed teeth

Michael Woodhouse — Fri, 28 Dec 2012 19:43:30 GMT

[quote user="Evelyn Barbour-Hill"]You will need to address the question of the pulp sooner or later, whether you elect to do a full pulp extirpation once the periodontium is sound, or to monitor with repeat examinations and periodic radiographs.[/quote]

But

[quote user="Neil Wheadon"]both charity cases[/quote]

I still think my suggestion is reasonable! They don't 'need' any teeth to lead a normal life.

Re: Replacing avulsed teeth

Evelyn Barbour-Hill — Fri, 28 Dec 2012 15:16:25 GMT

[quote user="james herriot lied"]I have often wondered how dogs are able to just flip out canines, with relatively little fuss, when it takes me all day with a bunch of elevators and an electric drill to surgically remove them.[/quote]

Because they break them out through the alveolar bone.

Re: Replacing avulsed teeth

Evelyn Barbour-Hill — Thu, 27 Dec 2012 21:09:02 GMT

Yes, the fact that these teeth were still in the mouth and still attached to bits of gum (and possibly odd bits of alveolar bone) made the prognosis better, as most certainly did the promptness of attention after the avulsion. If they sort of plop back in, and the gum flops back nicely and stays in place almost by suction, the prognosis for periodontal re-attachment is not bad. In such cases one often gets the impression that even the suturing of the gum helps stabilise.It's customary on the whole to stabilise them with wire and/or acrylic, given that you can hardly supply the dog with an athletic mouthguard or instruct it to be very very careful for the next six weeks.

Just remember however that it's the prognosis for periodontal attachment that's not bad. The pulp is not going to survive the severance of its blood supply. You will need to address the question of the pulp sooner or later, whether you elect to do a full pulp extirpation once the periodontium is sound, or to monitor with repeat examinations and periodic radiographs.

Re: Replacing avulsed teeth

Neil Wheadon — Thu, 27 Dec 2012 15:41:48 GMT

[quote user="Michael Woodhouse"]Personally I'm not sure I would have bothered - they are not going to miss them.[/quote]

Likewise cats with a broken leg, may as well amputate, they do just fine.

Happy New Year Michael

Re: Replacing avulsed teeth

Michael Woodhouse — Thu, 27 Dec 2012 09:43:37 GMT

Personally I'm not sure I would have bothered - they are not going to miss them. In people they do splint them, but my understanding from our friendly local dentist is that if replaced quickly there is a good chance of reattachment.

Re: Replacing avulsed teeth

James Laidlaw — Thu, 27 Dec 2012 08:59:06 GMT

Re: Replacing avulsed teeth

Anne Seawright — Wed, 26 Dec 2012 22:01:13 GMT

According to my dentist partner, the cells last for about 30 minutes in milk, but about an hour in saliva, so the fact the teeth were still in the mouths of these dogs is good! He would have suggested using a soft splint wire for 5 days to prevent them being avulsed with inflammation, but even under best conditions in people only about 50% will survive. So good luck!

Re: Replacing avulsed teeth

james herriot lied — Wed, 26 Dec 2012 20:55:45 GMT

I have often wondered how dogs are able to just flip out canines, with relatively little fuss, when it takes me all day with a bunch of elevators and an electric drill to surgically remove them.

My feeling is that they'll probably fail to root, particularly the incisors, but as you say - no lose. I doubt it'd take another anaesthetic to extract them.