208 weird rostral roots

Re: 208 weird rostral roots

Evelyn Barbour-Hill — Tue, 08 Apr 2014 19:22:19 GMT

Yum, thanks.

Re: 208 weird rostral roots

Suzanne Kelly — Tue, 08 Apr 2014 16:54:22 GMT

Hi all,

That's the rest of the radiographs, Sorry I couldn't manage to load them in order. I can;t find his dental chart from October, but I here are his notes:

"bloods biochem ok, haem mild anaemia 30.3 ( 35-55)

needed to premed to take bloods as fear aggressive ++

103 3mm pocket, 104 6mm pocket

extracted 101,107,108,109

rostral root 108 #, unable to retrieve as bled ++ and then went pale

sutured monocryl

extracted 403,405

4 mm pocket 404, xray ok

extracted 405

409 caudal pocket, xray ok

extracted 201,205

need to extract 208,209 but went pale so didn't

extracted 303,305

Missing 106,206,306,308,406,408, xrayed all ok"

These are his notes from the recent dental:

"Missing 101,106-109,205,206,303,305,306,308,403,406,408

pockets - 103 3mm, 104 5mm GR 2mmp, 108 has mark where 409 impinging, xrayed root there, no probs yet

203 3mm GR 2mmp, 204 4mm GR, 2mmp, 208 seems fine!!! but on xray rostral roots mottled, will email to specialist, so left re probs with impinging poss 309

209 seems ok 3mm pocket rostrally

301,302 crowded 304 5mm GR, 4mm pocket

401,402 crowded

404 3mm GR 3mm pocket

PLAN - email radiographs and see what response is!"

Ozzie is in great form, he's almost 14 years old. His chart has more detail, but we've moved premises and it's got misplaced.

Suzanne

Re: 208 weird rostral roots

Suzanne Kelly — Tue, 08 Apr 2014 16:42:29 GMT

Re: 208 weird rostral roots

Suzanne Kelly — Tue, 08 Apr 2014 16:41:30 GMT

Re: 208 weird rostral roots

Suzanne Kelly — Tue, 08 Apr 2014 16:32:18 GMT

Re: 208 weird rostral roots

John Flynn — Sun, 06 Apr 2014 19:21:24 GMT

[quote user="Evelyn Barbour-Hill"]You must try to take all adverse outcomes (including those on the owner's wallet), not to mention the surgeon's level of skilll and equipment into account and give each a suitable weight.[/quote]

I guess that's when it becomes less obvious and more disputable!

Re: 208 weird rostral roots

Evelyn Barbour-Hill — Sun, 06 Apr 2014 19:14:13 GMT

[quote user="John Flynn"]

Does this mean that "saving" a tooth is justified only when the morbidity and risk of adverse outcome are lower than that of extraction? i.e. in this instance is there an argument for "if in doubt take it out" in a case like this where the vet is in two minds at the time?

[/quote]

Yes of course, if you insert the word "obviously" or the word "indisputably" before "lower".

You must try to take all adverse outcomes (including those on the owner's wallet), not to mention the surgeon's level of skilll and equipment into account and give each a suitable weight.

[quote user="Suzanne Kelly"]I've more radiographs if anyone's interested.[/quote]

Ooh yes please.

Re: 208 weird rostral roots

Evelyn Barbour-Hill — Sun, 06 Apr 2014 19:06:19 GMT

[quote user="Suzanne Kelly"]When I probed 208 and 209 they were fine, the pockets had resolved and there was no mobility or furcation exposure.[/quote]

Well done! I'd call that pretty significant.

[quote user="Suzanne Kelly"]Ozzie is not the easiest to examine concious, examination is best achieved by trying to see into the mouth as he's gnashing and snapping at me! [/quote]

Ah yes.......... . Not a problem that human dentists have, I imagine.

Re: 208 weird rostral roots

John Flynn — Sun, 06 Apr 2014 19:04:17 GMT

I recently read an editorial in JAVMA (http://avmajournals.avma.org/doi/full/10.2460/javma.243.12.1680) that put it like this:

"A fundamental principle of veterinary medical ethics is that the potential benefits of a procedure must outweigh the potential risks and costs. This principle is easily stated but can be difficult to apply because there can be disagreements about what is good or harmful for animal patients and their owners and because what might be good for an individual patient could conflict with the owner's desires or best interests.

Potential benefits of medical procedures for dogs and cats include cure, palliation, or prevention of disease, infirmity, or pain; a continuing life; and a good quality of life. Potential benefits for their owners are the ability to continue to enjoy the human-animal bond and the continued use of a service or working animal.

Potential risks and costs of medical procedures for dogs and cats include the risk of death that might be associated with a procedure; pain, distress, or discomfort in association with or as a result of the procedure; and a poor or unimproved quality of life. Potential costs for their owners include the financial costs of the procedure and the physical and psychological burdens of caring for the animal during and after the procedure."

Interestingly, it went on like this:

"Following extraction of a single tooth or multiple teeth, dogs and cats are fully functional without substantial negative influence on their quality of life. They are able to not only eat and play but also engage in the gamut of activities that allow companion animals and their owners to enjoy the benefits of the human-animal bond. These favorable outcomes of tooth extraction have never been challenged in the scientific literature."

It made me think on a few accounts, but one was:

Re: 208 weird rostral roots

Suzanne Kelly — Sun, 06 Apr 2014 18:56:03 GMT

Hi all,

Thanks so much for the replies. I'm at home so don't have access to this little guy's notes, but this is what I can remember of them. I did a dental on Ozzie a few months back. He had loads of extractions, he had a horrible mouth. At the time 208 and 209 were scheduled for extraction due to periodontal disease and as far as I can remember fairly substantial pockets. I'll find the notes tomorrow so can be a bit more precise. As the anaesthetic progressed, he became quite pale. I then fractured one of the rostral roots of 108 and he bled a little when I went looking for it. At that point he became very pale, so I abandoned ship and told the owner we'd go back and tackle 208 and 209 another day.

Ozzie has been "asymptomatic" throughout and was prior to the original dental too despite having extensive dental disease.

I anaesthetised Ozzie again a couple of weeks ago. When I probed 208 and 209 they were fine, the pockets had resolved and there was no mobility or furcation exposure. The tip of the crown of 409 was impinging in the hard palate where 108 was and causing a bit of indentation. I wasn't happy to just go ahead and extract 208 and 209 without being fairly sure that extraction was in his best interests, especially as on the radiographs the roots looked so strange.

So I told the owners that the pockets had gone but the roots looked odd and I was going to ask for some advice. There are no vet dentists in Ireland, so referral is not an option. The anaesthetic was aok this time. Ozzie is not the easiest to examine concious, examination is best achieved by trying to see into the mouth as he's gnashing and snapping at me! The owner says he's very happy since the last dental and only wants extraction if absolutely necessary.

More info to follow once I get hold of his notes.

I've more radiographs if anyone's interested.

Thanks again,

Suzanne

Re: 208 weird rostral roots

Evelyn Barbour-Hill — Sun, 06 Apr 2014 18:39:34 GMT

[quote user="Evelyn Barbour-Hill"]If it's symptomless and the crown and gingiva look normal[/quote]

See how I neatly ducked the question there?

As I spend quite a lot of my life trying to convince owners and even veterinary surgeons that broken teeth have to be treated even though "he doesn't show any signs of it being painful at all", I did think thrice before suggesting present inaction in this case.

On balance , taking into account not only the "putting him through another GA" (a minor consideration if he is healthy), but the probable difficulty of extracting those roots properly with attendant risk of excessive tissue damage, and assuming that the vet-client relation is good so that it will be possible to monitor the tooth, I would not be insisting upon extraction at this time.

Absence of symptoms means the dog is eating perfectly OK and is doing nothing abnormal associated with the area of that tooth. There are ways of assessing further for more subtle signs (which, strictly speaking, are not symptoms, but let that pass), including careful examination of the crown, careful observation of the patient especially while eating, palpation of the root area, mechanical stimulation and so on. None of these are infallible, but they are helpful.

Re: 208 weird rostral roots

James Laidlaw — Sun, 06 Apr 2014 17:53:31 GMT

I think it depends on how you define "asymptomatic" - and how long you think it will remain that way.

Re: 208 weird rostral roots

John Flynn — Sun, 06 Apr 2014 16:34:07 GMT

[quote user="Anthony Dennison"]If it is an asymptomatic tooth in a 13 year old Westie, is it worth putting the dog through a GA to remove it? Genuinely interested, what with pro's and con's of a GA in an older dog.[/quote]

I assume the dog was under GA when the xray was taken and the question may therefore be being asked retrospectively: "Should I have extracted that tooth based on that xray?"

To put the dog through a further GA simply with the aim to extract this tooth would be pretty questionable in my mind?

Re: 208 weird rostral roots

Peter Southerden — Sat, 05 Apr 2014 23:08:44 GMT

I'd need to know more about the dog to say. The absence of obvious signs of pain (which isn't the same as saying it's not painful) has to be balanced against the evidence of what is likely to be an inflammatory process which may be causing pulpitis. I agree though that it isn't a straightforward decision.

Re: 208 weird rostral roots

Anthony Dennison — Sat, 05 Apr 2014 22:40:12 GMT

If it is an asymptomatic tooth in a 13 year old Westie, is it worth putting the dog through a GA to remove it? Genuinely interested, what with pro's and con's of a GA in an older dog.

Re: 208 weird rostral roots

Peter Southerden — Sat, 05 Apr 2014 22:24:43 GMT

Hi Suzanne

Your X-rays are good - you've achieved separation of all three roots which is what you want to do.

There is external replacement resorption of the mesio-palatal and mesio-buccal roots of the left maxillary fourth premolar. There may also be early resorption of the mid section of the distal root. On balance, from what I can see on x-ray alone, I would extract this tooth. With the degree of root resorption that is evident it is likely that this tooth will have pulpitis.

Also if you look at the maxillary third premolar it would appear that the pulp chamber is obliterated in this tooth. This again could be the result of a low grade chronic pulpitis. In a patient like this I would probably take full mouth rads as there may well be significant pathology elsewhere. Did this dog have excessive wear or any other obvious pathology?

Out of interest what made you x-ray the fourth premolar in the first place?

Yours

Pete

Re: 208 weird rostral roots

Evelyn Barbour-Hill — Fri, 04 Apr 2014 15:28:46 GMT

I reckon that's resorption but it's just possible the tooth formed that way. In my opinion.

Your radiographs are OK.

If it's symptomless and the crown and gingiva look normal, I wouldn't do anything, me.