Breakdown of lower canine extraction site

Re: Breakdown of lower canine extraction site

Evelyn Barbour-Hill — Tue, 16 Dec 2014 21:57:33 GMT

Happy ending.

Re: Breakdown of lower canine extraction site

Suzanne Kelly — Tue, 16 Dec 2014 21:54:02 GMT

Update - post op check today, all healed up now. One of the nurses has adopted him so staffy smiles all round :)

Re: Breakdown of lower canine extraction site

Rob Davis — Tue, 09 Dec 2014 20:04:15 GMT

[quote user="Anthony Todd"]

Point well taken, and we would have investigated one like this too and suspected root fragments. Reassured to hear that in this modern day and age the old problems still occur.

To be fair and honest I reckon we would have probably given it steroids and called it "gingivitis", at least initially, although you can often palpate root fragments that close to the surface.

Nice riposte though! [retires, huffing and puffing, trying to think of a mitigating response....]

[/quote]

Wow - I didn't see that coming!

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 19:42:41 GMT

[quote user="Rob Davis"]He came in because of oral pain and significant inflammation in the gingiva overlying these remnants. Note the needle to allow me to accurately localise the roots as they were NOT visible![/quote]

So how did you know where to place the needle?? BOOM BOOM

Point well taken, and we would have investigated one like this too and suspected root fragments. Reassured to hear that in this modern day and age the old problems still occur.

To be fair and honest I reckon we would have probably given it steroids and called it "gingivitis", at least initially, although you can often palpate root fragments that close to the surface.

Nice riposte though! [retires, huffing and puffing, trying to think of a mitigating response....]

Re: Breakdown of lower canine extraction site

Rob Davis — Tue, 09 Dec 2014 19:25:15 GMT

[quote user="Anthony Todd"]Well you're now suggesting we all went round leaving roots in and didn't notice... you can see them, you know; don't need an Xray .[/quote]

I wish I had your x-ray vision!

For example: this cat had a "total extraction" performed elsewhere 4 years before the radiographs below were taken. He came in because of oral pain and significant inflammation in the gingiva overlying these remnants. Note the needle to allow me to accurately localise the roots as they were NOT visible!

Not perhaps the best example, but the first one I came accross on my computer.

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 19:12:13 GMT

[quote user="Rob Davis"]particularly root remnants in cats which often cause significant pain.[/quote]

Too true, boy, some posters do wildly stretch their argument.

I'm not saying I never left a root, I am saying I went in and removed it, admitted the error, [tried a bit of cringing mitigation] and didn't charge the client either.

Mind you some "retained" roots seemed totally symptomless though.

[quote user="Rob Davis"]Doh! I'm getting sucked in again....[/quote]

Well you're now suggesting we all went round leaving roots in and didn't notice... you can see them, you know; don't need an Xray .

Re: Breakdown of lower canine extraction site

Rob Davis — Tue, 09 Dec 2014 19:03:11 GMT

[quote user="Anthony Todd"]So all our dentals ['cos we all did them that way] were in agony for weeks, back for antibiotics, reanaesthetic, more Xrays, more agony, dissatisfied clients?[/quote]

I'm not sure where this came from.... I don't remember anybody suggesting this! You do have a habit of tending to see everything in black and white.

I do know, from my own personal experience, that my dental patients recover more quickly and have better long term oral health since I made the effort to improve my knowledge and skills and to improve our equipment. I still regularly see patients with oral problems resulting from previous poor dentistry, particularly root remnants in cats which often cause significant pain. It is only since I started regularly taking intra-oral radiographs that I began to appreciate how much pathology I had previously been missing.... just because the dog/cat goes home and eats, it doesn't mean you've done a good job!

[quote user="Anthony Todd"][quote user="Rob Davis"]but lost the will to continue before I'd really got started... we've been here before and some opinions will not be changed.[/quote][/quote]

Doh! I'm getting sucked in again....

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 18:24:22 GMT

[quote user="Rob Davis"]but lost the will to continue before I'd really got started... we've been here before and some opinions will not be changed.[/quote]

So all our dentals ['cos we all did them that way] were in agony for weeks, back for antibiotics, reanaesthetic, more Xrays, more agony, dissatisfied clients?

It just didn't happen that way often, if ever. That's all I've ever been saying., not that the new methods and techniques don't work, or aren't better, [although we can't compare] just that the old ones seemed to work too.

Re: Breakdown of lower canine extraction site

Rob Davis — Tue, 09 Dec 2014 18:07:37 GMT

Well done Suzanne - right decision!

I too spent my first few years in practice struggling with dentistry with very little knowledge of what I was trying to achieve, let alone how to achieve it. In the last 10 years dentistry has become my primary interest... I try not to remember how I used to do things...

[quote user="Evelyn Barbour-Hill"]Have we got a "patient sigh" emoticon?[/quote]

I did start a reply to Anthony, but lost the will to continue before I'd really got started... we've been here before and some opinions will not be changed.

Re: Breakdown of lower canine extraction site

Evelyn Barbour-Hill — Tue, 09 Dec 2014 17:21:14 GMT

[quote user="Anthony Todd"]

[quote user="Evelyn Barbour-Hill"]Or admit to it, anyway.[/quote]

Come on Evelyn, I've always been very honest about mistakes and errors, and I've had loads.

Remember "experience" is when you realise you've made the same mistake again......

When did vets start removing the lateral alveolar wall? I stopped in 2000 and AFAIK nobody I knew was doing it then for canine extraction and I know everyone said they took time and were a pain to do the old way but we really didn't get problems.

The irony is that the OP had "problems", using the "new", not the "old" discredited, way.

Hence her post!

[/quote]

Have we got a "patient sigh" emoticon?

Anthony:

[quote user="Suzanne Kelly"] I've probably done 100s of lower canine surgical extractions, this is the first one that's broken down on me.[/quote]

and also:

[quote user="Suzanne Kelly"]There was a chunk of necrotic bone in there so it's all debrided and flushed and sutured.[/quote]

There you go. So actually you were right to go back in and re-do it, when we were all saying leave it!

[quote user="Anthony Todd"]everyone said they took time and were a pain to do the old way but we really didn't get problems.[/quote]

"What, never?" (Gilbert WS, Sullivan A, HMS Pinafore)

Could be you only attempted canine canine extraction when the perodontal attachment was already severely compromised.

[quote user="Anthony Todd"]As I understand it removing the lateral alveolar wall must necessitate detaching the bone from the root laterally,which must be fiddley, and then from the other 240 degrees of attachment so I can't see how this differs with regard to the separation except you should be able just to lever the tooth or root laterally rather than actually extract it.[/quote]

No, you don't detach the plate of bone from the tooth at all. You cut around the outline of the tooth, as it were, ideally cutting only into the periodontal space. And when i do it, I free considerably more thah 120° of tooth circumference – more than 180° if I can.

I don't really feel like entering into a lengthy and accurate description with essential diagrams. It's easier to demonstrate than describe. It will be in the textbooks.

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 17:10:11 GMT

Sorry Suzanne, this wasn't personal at all just the case and the scenario.

I don't feel at all cringey at the post op behaviour back in the days of "dentals" 'cos they seemed totally OK and eating once the longish acting GA wore off.

And now we've got no way of comparing post op. performance. I wonder if there are any practices where [probably] the boss does "dentals" and someone else does "dental surgery" or the way most human dentists do it, so we could compare post op performance, then I'd have to shut my trap....

Re: Breakdown of lower canine extraction site

Suzanne Kelly — Tue, 09 Dec 2014 15:53:13 GMT

The deed is done! Successfully I hope, thanks Rob and Evelyn. There was a chunk of necrotic bone in there so it's all debrided and flushed and sutured. I tried to upload a pic but can't on the iPhone, I'll have a go later. My main concern was how to get a big enough flap without compromising the frenulum or worse the mental foremen in a dog with his face shape. I've probably done 100s of lower canine surgical extractions, this is the first one that's broken down on me. The dog is a stray, it's a very long story( not going into it here) , lovely dog but the mere mention of his name winds up one of the partners so it's easier not to tell him. The other partners are fine with it and fully aware that he had his op this morning. I'm 20 years qualified in June does that make me a dinovet or a baby dino? I spent the first 10 years doing what I thought was a perfectly acceptable job doing dentals, the last 10 trying to make up for it and in the horrors of what I thought was acceptable before. Each to their own, but I always suture sockets if I can and pretty much always take radiographs too. The more I learn now, the more I cringe at what I used to do, but that's just me. To me there's no comparison with how the animals are post op now compared to how they used to be - apart from 1 socket on 1 controversial staffie :)

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 15:01:22 GMT

[quote user="Evelyn Barbour-Hill"]Or admit to it, anyway.[/quote]

Come on Evelyn, I've always been very honest about mistakes and errors, and I've had loads.

Remember "experience" is when you realise you've made the same mistake again......

The irony is that the OP had "problems", using the "new", not the "old" discredited, way.

Hence her post!

As I understand it removing the lateral alveolar wall must necessitate detaching the bone from the root laterally,which must be fiddley, and then from the other 240 degrees of attachment so I can't see how this differs with regard to the separation except you should be able just to lever the tooth or root laterally rather than actually extract it.

How does one actually cut the lateral alveolar wall away to begin with or can you direct me to a link that describes it please.

Re: Breakdown of lower canine extraction site

Sammy82 — Tue, 09 Dec 2014 14:34:31 GMT

Of course you mustn't go and see paying clients pets outside work, but if the alternatives are checkup/treatment FOC at the practice or the dog not being seen again at all? The better option of course would be to get some money from somewhere (PDSA etc.) or treat it FOC with the Bosses consent whilst trying to keep costs to the practice to a minimum.

Re: Breakdown of lower canine extraction site

Evelyn Barbour-Hill — Tue, 09 Dec 2014 14:19:44 GMT

[quote user="Anthony Todd"]I'll check with fellow dinovets but I'll be very surprised if they had problems, ever, doing it the old "traumatic" way.[/quote]

Or admit to it, anyway.

Does a period of 42 years qualify me as a dinovet?

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 14:12:31 GMT

[quote user="Sammy82"]I think we sometimes worry to much about stitching wounds just because we can.[/quote]

Just realised.... the OP's wound broke down...... see what I mean....

I'll check with fellow dinovets but I'll be very surprised if they had problems, ever, doing it the old "traumatic" way.

Re: Breakdown of lower canine extraction site

Gillian Mostyn — Tue, 09 Dec 2014 13:20:39 GMT

[quote user="Sammy82"] Checking the dog again a couple of times will be much cheaper for the practice. If bringing the dog back for a check up is frowned upon by your boss you could possibly even go and see it in the street, after work so nobody can complain about having to pay your time?[/quote]

I know what you're getting at- and you mean well - but this would be a very bad idea. It is all too easy for assistants to end up seeing pets outside of work hours and it can be seen as a generous gesture, but, if you think about it, the assistant is being generous with the boss' money! We can all be generous when it is someone else's income that is reduced rather than ours. Most contracts forbid employees from doing any work outside of the workplace for this reason - ignoring this may lead to disciplinary action.

(This situation - where the pet is only known to the assistant through work, is obviously different to helping close friends and family which most employers would expect! At least I would.. )

Re: Breakdown of lower canine extraction site

Sammy82 — Tue, 09 Dec 2014 12:20:08 GMT

I would leave it to granulate, maybe give it some ABs if it is still infected. It will heal eventually even if it takes a bit longer. You/the practice is worried about costs, and trying to fix a broken down wound will cost anaesthetics, material, theatre time, pre/post op care.... with a risk of it breaking down again. Checking the dog again a couple of times will be much cheaper for the practice. If bringing the dog back for a check up is frowned upon by your boss you could possibly even go and see it in the street, after work so nobody can complain about having to pay your time?

I think we sometimes worry to much about stitching wounds just because we can. Of course quite often it is the better choice, preventing it getting contaminated, it heals quicker, leaves less of a scar... but sometimes we would be better leaving it alone, e.g. bite wounds or other infected wounds, old wounds, superficial broken down wounds...The body is very capable of healing even large defects if we give it a chance to do so.

Re: Breakdown of lower canine extraction site

Anthony Todd — Tue, 09 Dec 2014 07:28:14 GMT

[quote user="Evelyn Barbour-Hill"]Sigh.....[/quote]

"Yes Anthony, but you never did a surgical extraction of a dog's canine teeth. That is what the OP did here, quite correctly since it is d. near impossible to extract the tooth any other way if its periodontal attachment is not already severely reduced. "

No I ,and others, never did. what doesn't seem to be accepted is that we removed the canine or the canine root as I have described with, apparently total success, no apparent pain, no "complications" or problems, so I'm at a loss to see why this old way is discredited, although with no actual experience of the method at all.

I also find it hard to believe that "complications" with the flap of gum do not occur sometimes, leaving a large area of socket exposed with the added risk of the clot being dislodged.

I appreciate completely that removing the lateral wall has all sorts of theoretical advantages but, in practice, and we all did lots, our way worked fine.

As some say, "end of".

Re: Breakdown of lower canine extraction site

Evelyn Barbour-Hill — Mon, 08 Dec 2014 23:15:04 GMT

[quote user="Anthony Todd"]To howls of disgust and derision I have to say that I and my practice never sutured any extraction in a cat or dog ever[/quote]

Yes Anthony, but you never did a surgical extraction of a dog's canine teeth. That is what the OP did here, quite correctly since it is d. near impossible to extract the tooth any other way if its periodontal attachment is not already severely reduced. So, of course, suturing is involved. Sigh.....

[quote user="Neil Wheadon"]2) Thought that you could leave 1/2 - 1/3 root in situ with no problems. They would uneventfully work there way out, maybe Anthony's experience?[/quote]

It depends, of course, on the reason for which you were extracting the tooth in the first place.

We've been through all this before, and neither "always make huge efforts to extract broken roots" nor "hey, it's OK to leave half the root in, she'll be right" are correct. Neither "alveoli should always be sutured" (yes, I've heard that from some American) nor "never bother to suture alveoli" is correct. There are many situations where suturing is desirable, even important, and several different reasons for doing it. In other simple situations it is indeed pointless.

Human dentistry is important for us to study, but sometimes only from a comparative point of view. Some veterinarians and some human dentists appear to believe that you can, nay should, translate human dentistry directly to dogs. They are wrong.

None of which is any help or even relevance to the OP.

Suzanne:

I sympathise with you! I think what everyone else sensible has already said does about cover it. You'd have to do a lot more mobilisation of soft tissue and probably a bit more bone removal (the Americans call this osteoplasty), and then after all that you might find that it breaks down again....

Accepting the breakdown and leaving it to granulate may well feel unsatisfactory and third-best, but it's what, 85% certain that it will heal uneventfully, unless you've left great spicules of bone edge standing up, or semifractured bits in the alveolus that are going to become sequestrae..... which, knowing you, I doubt is the case.

GIven the internal political situation, I'm sure it's the best thing to do.

Pain relief of course, and an antibiotic .

Re: Breakdown of lower canine extraction site

Gillian Mostyn — Mon, 08 Dec 2014 22:37:46 GMT

Anthony...this is a serious question.... Had you ever done any seeing practice or CPD where you had seen a canine root removed by alveolar bone removal? I genuinely ask because if you hadnt, you may have found it useful. Trying to dig a well attached canine root out is horrible, and is almost certainly going to cause massive trauma to the area. Yes, as you have found, it is possible. And the area will heal (although an oronasal fistula is an increased risk) but it really isn't the best method though. If that was my method, I am happy to admit I would be more likely to leave in teeth that should really be removed!

Re: Breakdown of lower canine extraction site

Anthony Todd — Mon, 08 Dec 2014 22:08:40 GMT

Sorry duplicated, no idea why. I blame Arlo always....

Re: Breakdown of lower canine extraction site

Anthony Todd — Mon, 08 Dec 2014 22:08:17 GMT

[quote user="Gillian Mostyn"]

How the bejesus do you remove a healthy canine root WITHOUT removing the lateral alveolar bone?

[/quote]

If you were lucky enough to have an automatic mallet [criticised by the experts last time this came up] it was a doddle otherwise it was a case of persistent elevation.

Despite the experts' doubts we never had a problem and, post op., the dogs all seemed fine.

Re: Breakdown of lower canine extraction site

Gillian Mostyn — Mon, 08 Dec 2014 21:37:47 GMT

How the bejesus do you remove a healthy canine root WITHOUT removing the lateral alveolar bone?

Re: Breakdown of lower canine extraction site

Anthony Todd — Mon, 08 Dec 2014 20:07:36 GMT

[quote user="Martin Atkinson"]However, I do agree that sometimes when extracting K9s it is easier to raise a gingival flap and remove the lateral alveolar bone. Then you've got to sew the flap back or you have exposed bone not just big hole where the root was![/quote]

Sure, not that I ever had to, but if you remove lateral alveolar bone I think I'd sew a flap back too.