Tooth Extraction

RE: Tooth Extraction

Iain Richards — Wed, 07 Sep 2016 09:31:29 GMT

Thanks Peter & Evelyn. In future, I'll be comfortable making a decision not to chase a tiny tip as a result, especially in an older patient I'm keen to get off the table. Especially if I have radiography for it.

As an aside, this could be a good example of the reflective way we are told we should do CPD. I've had an experience, found out some new information, balanced it against what I know and have concluded what I will do with it. Sadly as I haven't planned it, it won't count in the "Plan, Do, Record, Reflect" mantra.

RE: Tooth Extraction

Hannah Wynne Richards — Wed, 07 Sep 2016 07:25:15 GMT

If it had gingivitis, then I bet if it could talk, it would have said its mouth was sore. It wasn't fine, it had unobservant owners.

Wynne

RE: Tooth Extraction

Anthony Todd — Wed, 07 Sep 2016 01:00:24 GMT

[quote user="Evelyn Barbour-Hill"]If it's got surrounding gingivitis it's not fine![/quote]

You miss the point though which was whether retained roots, and mine was an extreme example[!], would be obvious by the cats' behaviour and, in this case, as I said, the cat seemed fine according to the owner. I think it came in for a vaccination.

I did remove all the roots, after explaining the consequences, and the cat remained fine....

RE: Tooth Extraction

Peter Southerden — Tue, 06 Sep 2016 21:10:07 GMT

Hi Ian - There is little published in the veterinary literature which will help guide your decision making. A good reference in the human dental literature is "Fractured root tips during dental extractions and retained root fragments. A clinical dilemma? BDJ 2015;218:69-74" It reports a complication rate of between 16 and 27% from retained root fragments presenting as pain, infection or sinus formation. I quote from it "Clinicians should carry out a risk benefit matrix analysis when considering the removal of retained roots for each individual patient. If it is decided to leave a retained root fragments in situ, the dentist is obliged to advise the patient, and to ensure regular clinical and radiological follow up while taking into account safe radiation exposure guidelines." Generally if the root fragment is from a non vital tooth it should be removed. If you see a root fragment with evidence of infection associated with it it should be removed. If you decide to leave a root fragment then the owner should be informed, the extraction site closed (there is an increased risk of fistula formation if you don't), the case followed up radio graphically. So it is not acceptable just to leave root fragments but there should be a rational clinical decision made based on the evidence, including x Ray's, the risk/benefit of removal and then a plan to follow the case up. If we are going to extract root remnants, in my opinion, we should be able to take and interpret dental x-Ray's and have the required surgical skill in order to minimise the risk of post operative complications. If not then the case should be referred to a colleague who can. I think we should adopt a more cautious approach than our human dental colleagues because it is notoriously difficult for owners to detect mild/moderate pain symptoms in our patients and therefore complications are likely to be under reported. Best wishes Peter

RE: Tooth Extraction

Evelyn Barbour-Hill — Tue, 06 Sep 2016 14:49:50 GMT

[quote user="Anthony Todd"]I've seen cats with rows of molar fence posts and, apart from surrounding gingivitis, the cat seems fine and the owner confirms it....[/quote]

If it's got surrounding gingivitis it's not fine!

RE: Tooth Extraction

Evelyn Barbour-Hill — Tue, 06 Sep 2016 14:48:33 GMT

[quote user="Iain Richards"]As I understood it, removing broken tips was due to the pain of those left.[/quote]

No.

Removing broken tips is to complete the job you were doing in the first place.

Whether it is essential depends upon why you were extracting the tooth. What disease process are you treating? Will it continue if there is root left? If you had an infected pulp, you've left some behind in the root tip. If you were extracting for periodontal disease, you're OK as long as the broken tip is deeper than the level the periodontitis had reached. If you are doing a mass extraction for feline chronic gingivostomatitis, it will be a failure if you leave any root bits behind (something we don't quite understand, but it is a fact). If you are "extracting"- removing, rather - a severely FORL-affected tooth, then obviously bits of root left behind will just continue to resorb – not painful as long as they are well buried.

By the way, anybody "digging out" a root fragment is doing something wrong.

And, er...[quote user="Iain Richards"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Iain Richards"]if it bothers the dog/cat we’ll re-do for free.[/quote]

P.S.

That's fine, but how will you know if it bothers the patient?

[/quote]

How will you?

RE: Tooth Extraction

Anthony Todd — Tue, 06 Sep 2016 10:36:33 GMT

I've seen cats with rows of molar fence posts and, apart from surrounding gingivitis, the cat seems fine and the owner confirms it....

A hanging fragment is a different story giving obvious discomfit, salivation and tongue distress, particularly with incisors.

RE: Tooth Extraction

Bob Russell — Tue, 06 Sep 2016 10:25:13 GMT

I no longer go into melt down if I leave a fragment of root. I do warn owners though.

My concern is that people can easily tell if a root is painful and this is not so clear cut in pets!

If you X-ray cats mouths regularly it is not uncommon to find root fragments in place (crowns presumably broken off secondary to FORL's). Gums look perfect and roots becoming incorporated into jaw bone.

One of the many advantages of dental X-rays is you can monitor for bone lysis etc!

RE: Tooth Extraction

Iain Richards — Tue, 06 Sep 2016 07:50:52 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Iain Richards"]if it bothers the dog/cat we’ll re-do for free.[/quote]

P.S.

That's fine, but how will you know if it bothers the patient?

[/quote]

As I understood it, removing broken tips was due to the pain of those left. But this doesn't seem to be reported in humans, so why should it be so in animals? Apparently the tips wall off or migrate out. Which sounds plausible to me.

RE: Tooth Extraction

Evelyn Barbour-Hill — Mon, 05 Sep 2016 22:35:20 GMT

[quote user="Iain Richards"]if it bothers the dog/cat we’ll re-do for free.[/quote]

P.S.

That's fine, but how will you know if it bothers the patient?

RE: Tooth Extraction

Evelyn Barbour-Hill — Mon, 05 Sep 2016 22:33:47 GMT

As i've said several times before, it depends on the reason for which you were doing the extraction in the first place.

Some broken tips can be left.

It doesn't mean you should get careless about doing your best to either extract the tooth intact, or to remove the broken bit if you can without much extra trauma.

And i'm in a grumpy mood, so I'll add that much small animal dentistry is done very badly already. I don't want the fact that some broken tips can be left to become an excuse for laziness.

RE: Tooth Extraction

Neil Wheadon — Mon, 05 Sep 2016 22:19:59 GMT

We have 2 dentists who come cycling and both have said the same thing, it doesn't matter if you snap a tip. I think you can leave 1/3 of the root in adults

Neil

RE: Tooth Extraction

Iain Richards — Mon, 05 Sep 2016 21:24:27 GMT

Not any more! (sorry, yes it was)

RE: Tooth Extraction

Liz w — Mon, 05 Sep 2016 20:17:31 GMT

Was it a permanent tooth?