Help with chipped carnassial please!

RE: Help with chipped carnassial please!

Bob Partridge — Mon, 05 Sep 2022 18:58:34 GMT

Just another 2p's worth

Advising "wait & see" is not an option (IMHO).

If the client chooses to take that option - that is their choice & their responsibility under legislation.

Some of the most upsetting cases I see are osteomyelitis cases resulting from failure to close sockets (or flap failures) after extraction. But if you want to run that risk for your patients - so be it.

Personally I also zip off the crown - allows easier access for luxators to follow the root (examine the normal bulge of the crown over the root). Again - personally, I can't see the benefit of a closed extraction if you are then going to raise a flap to close the site. Why not create a flap at the start and make easier access.

And to Bibs - don't sweat it. You can only offer the best advice & do your best. There will be plenty of opportunities for the "Well I did tell you..." internally vocalised of course.

RE: Help with chipped carnassial please!

Rachel Perry — Fri, 02 Sep 2022 16:11:46 GMT

I agree with Rob, Bibs. You can go home at night knowing you did your best for the patient. But, I have been there too before I was a Specialist, and it's sooooo annoying!

This article is an interesting read and reflects Rob's observation.

https://doi.org/10.5326/JAAHA-MS-5977

I too have seen many root fragments retained, which perhaps is a tangent off this thread..

RE: Help with chipped carnassial please!

Rob Davis — Fri, 02 Sep 2022 15:57:00 GMT

You are definitely NOT the chump in this scenario! As others have said, these often will get left (and probably more often not noticed by the client), but that doesn't make it ok for us to legitimise that decision.

I would add another option to Rachel's excellent description of an upper carnassial extraction: I like to cut off the whole crown after raising the triangle flap. This allows excellent visualisation of the periodontal ligament all around all three roots and reduced the risk of fracturing the root by placing inappropriate forces on the crown.

Michael Woodhouse I'm sure that this doesn't apply to you, but I frequently see root remnants from these teeth after extractions elsewhere (especially the mesio-palatal root), and usually the vet is convinced that they extracted everything. Radiography is key....

RE: Help with chipped carnassial please!

Bibs — Fri, 02 Sep 2022 15:11:26 GMT

This is one of those cases where the vet who’s just been to CPD advises treatment, the client isn’t happy and goes to see your older and more wise colleague, who suggests it’s fine to wait and see. Then you feel like a chump and the owner thinks you’re one too. This is a scenario I have faced a few times.

RE: Help with chipped carnassial please!

Sarah Wheadon — Fri, 02 Sep 2022 14:11:16 GMT

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238936#238936"]It shouldn’t be difficult if you know how.[/quote]

And thanks to one of Rachel's practical courses, I now (almost) look forward to one of these extractions.

RE: Help with chipped carnassial please!

Rachel Perry — Fri, 02 Sep 2022 06:14:51 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238950#238950"]I also think, if the owners chose to remove the tooth, that splitting in 3 with a burr I can have it out faster than Rachel with her flaps and sutures using sharp elevators/luxators with a conventional approach........[/quote]

I actually doubt it- in my hands at least. And for those inexperienced in extractions, this technique will work out quicker, because the bone removal is removing attachment for the root, making it easier/faster to extract and also far less likely to break. If an elevation (rather than lunation) technique is used, there is a risk of more peripheral trauma by compressing the alveolar bone, which could compromise healing times. What will undoubtedly be quicker with an open technique is healing, because primary intention wound healing in the mouth is far quicker, and less prone to complications than leaving an open socket to granulate. That's biology. Leaving the maxillary 4th pre-molar sockets open to granulate runs the risk of losing blood clots which are vital for healing, running the risk of alveolar osteitis.

RE: Help with chipped carnassial please!

Evelyn Barbour-Hill — Fri, 02 Sep 2022 01:42:44 GMT

[quote userid="28602" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238931#238931"]any top tips appreciated!![/quote]

A couple more:

Radiograph before starting, in case there are any unexpected weird shapes to the roots, like a curl at the apex for instance.

Review the anatomy of the tooth until you can visualise as you go exactly what it is you are trying to do. The curves and the angles will catch you out if you don't.

Be patient. Take as long as it takes. Speed is not vital. If the nurse starts yawning or drumming her fingers, or the boss looks in and starts moaning, invite them to do it themselves if they are so clever (under your breath unless you are very brave)

RE: Help with chipped carnassial please!

Evelyn Barbour-Hill — Fri, 02 Sep 2022 01:32:21 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238950#238950"] My neighbour (human dentist who now looks after my teeth) tells me with time the nerve regresses and tooth stops being painful. [/quote]

Michael, Rachel and Norman can speak for themselves and probably will, but for myself I'll say that I don't give advice to be a cleverdick, I give it because it's right .It's well understood that once the pulp has necrosed the tooth stops hurting. After that, there is an inevitable reaction around the apex and slowly but surely toothache develops. It may be delayed and slow but it's sure. It's such a dull slowly developing sort of pain you may not realise it's there until you do some thing to relieve it, and all of a sudden that dog you thought was just getting a bit old is running around and playing again. While we're on personal anecdotes, I discovered that the hard way in my own dog many years ago, and I'm very ashamed of it – all I can say is that it was a long time ago when I was rather ignorant.

Choose to leave? Sure, you could choose to leave a broken femur – it will knit in time. In fact I'd rather neglect the femur than the tooth, because the femur will probably stop hurting completely, eventually.

Perhaps. Perhaps you are fortunate enough to be as good as me at extractions, though I'd use luxators exclusively and no elevators. But Rachel was giving advice to someone who it seemed was quite apprehensive and had asked for some tips. There are plenty of veterinary surgeons, some of whom read this forum, who are similarly nervous about such a tooth.

I'd be happy to teach anyone my methods of extracting an upper 8 by "closed" technique, preferably by live demonstration, but the "open" technique advised by Rachel is equally good, especially for the tyro.

RE: Help with chipped carnassial please!

Norman Johnston — Thu, 01 Sep 2022 21:05:16 GMT

In my working life the owners that listened to advice least were vets, dentists and medics. All often happy to do nothing and wait - because they knew better? It’s easy to be the hero and say let’s wait and see. It costs less and involves no GA. If owners trust your advice then they leave happy. In my lectures I called it the conspiracy of inaction. The vet and owner agree to do nothing and the animal in the middle is left in limbo and pain. Three vet dentists have described the problem here. Probable pulp exposure and pulpitis. Subgingival fracture leading to periodontal pocketing and infection and the rough jagged tooth surface ripping the overlying mucosa to bits.
I’ve no axe to grind but advise the reality and don’t pretend it might be ok. It won’t.

RE: Help with chipped carnassial please!

Clive Ansell — Thu, 01 Sep 2022 20:23:25 GMT

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238938#238938"]While I absolutely understand your point that many clients may choose willingly or unwillingly the ‘do nothing’ approach that doesn’t mean that should be what we recommend as a veterinary professional.[/quote]

Thank you. I accept it and agree entirely, but in many cases there will not be a choice due to client and cost constraints.

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238938#238938"]I often wonder what is being monitored[/quote]

I suppose if one is just going to monitor, it should at least involve periodic radiography to look for appearance or progression of any pathology? But, if going to that amount of expense, may as well just extract?

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238938#238938"]make the right recommendation, then let the client decide - don’t pre-empt client decisions. [/quote]

That's what I do in all situations. I advise what I consider best clinical practice, then work backwards from that

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please/238938#238938"]pulpitis hurts![/quote]

I know, I've had it! I had a root canal filling in a maxillary molar in the 90's. A 3 rooted tooth that has 4 root canals (Not that uncommon I'm told), and only 3 were filled, I later had pulpitis in the remaining untreated canal. It was fine for many years, then started aching on and off before pain got worse. Nothing obvious on radiography. It has been redone and is now fine.

RE: Help with chipped carnassial please!

Michael Woodhouse — Thu, 01 Sep 2022 20:09:48 GMT

Whilst I agree that I would advise removal, many clients would chose to leave. If it was my dog, I'd wait and see (she has a fractured canine with pulp exposure). With the state of NHS human dentistry I had exposed pulp for about 18 months and it wasn't that bad. My neighbour (human dentist who now looks after my teeth) tells me with time the nerve regresses and tooth stops being painful.

I also think, if the owners chose to remove the tooth, that splitting in 3 with a burr I can have it out faster than Rachel with her flaps and sutures using sharp elevators/luxators with a conventional approach........

RE: Help with chipped carnassial please!

Rachel Perry — Thu, 01 Sep 2022 16:23:51 GMT

Just a comment regarding this Clive. While I absolutely understand your point that many clients may choose willingly or unwillingly the ‘do nothing’ approach that doesn’t mean that should be what we recommend as a veterinary professional. I have read this in many clinical notes over the years- ‘monitor for now as not causing a problem’ or ‘would be difficult to extract as otherwise solid’ . I often wonder what is being monitored - what might change to alter the vet’s recommendation? These teeth often do not cause a large facial swelling, nor draining sinus tract. Dogs and cats don’t stop eating if it hurts. But that does not mean the pulp isn’t compromised / inflamed (pulpitis hurts!) or necrotic with subsequent abscess/granuloma formation - which may be very sore. So, make the right recommendation, then let the client decide - don’t pre-empt client decisions.

RE: Help with chipped carnassial please!

Rachel Perry — Thu, 01 Sep 2022 16:14:38 GMT

It shouldn’t be difficult if you know how.

raise a mucogingival flap. I use a triangular shape with vertical release just mesial (rostral) to the carnassial. Extend the horizontal incision (which is made within the sulcus) a few mm onto molar 1. Raise the flap with a sharp periosteal elevator - ensure you raise beyond mucogingival junction.
Then remove buccal bone overlying the distal root and mesiobuccal root- perhaps to half the length of the root . I like a 701L for this. Be sure to delineate periodontal ligament spaces at mesial and distal aspect of both of these roots.
I then section the distal root in line with mesial sorface of the distal root. You can then use a wheel-and-axle technique to ‘elevate’ this triangular shaped root.
then I section the palatal root from mesiobuccal.
extract the mesiobuccal root next.
then remove a small amount of inter-radicular bone which is on the buccal surface of the palatal root. Extract this root last, and with care- it’s the one which likes to break!

smooth off bone with a fine diamond bur then make periosteal releasing incisions to close the flap and suture without tension.
post-op radiograph to ensure nothing left behind.
ensure instruments are sharp!

RE: Help with chipped carnassial please!

Aly Malcolm — Thu, 01 Sep 2022 15:44:09 GMT

I just would like to thank everyone who has taken the time to help me with this case and offer your advice. It is greatly appreciated. I should have said he is a 4yo Golden Retriever (mn). I think the client wants to have the tooth extracted but like everyone says it will probably be very difficult, any top tips appreciated!!

Best wishes

Aly

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Clive Ansell — Thu, 01 Sep 2022 10:12:07 GMT

[quote userid="6550" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30399/help-with-chipped-carnassial-please-this-tooth-appears-to-have-chipped-off-enamel-you-can-see-the-pulp-but-it-doesn-t-appear-actually-exposed-please-can-i-have-opinions-on-best-course-of-action-on-nsaids/238923#238923"]I suspect Clive was not suggesting it is fine to leave this tooth but that may well be an option suggested by some![/quote]

Thanks Bob, I didn't word my post very well.

Just monitoring or doing nothing would not be my advice or prefered option, but it is nevertheless an option that many of the clients I see would face. I did also suggest that it may be fine, but doubtful and likely need extraction.

Where I am working, in a very deprived area, folk mostly have no money or insurance so a dental referral would not be possible. Most wouldn't or couldn't pay for extraction either until it becomes a crisis and their hand is forced. I would be trying to convince them to book in for extraction.

So, down at the coal face on planet real world, it would in many cases, be case of wait and see, just monitor, do nothing. Not ideal or textbook , but that's the way of it.

It's great to get the opinion on such a short thread of 3 referral dentists, many thanks indeed.

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Bob Russell — Thu, 01 Sep 2022 08:34:36 GMT

I suspect Clive was not suggesting it is fine to leave this tooth but that may well be an option suggested by some!

I had a 'I wish I'd never started job' yesterday. A quick job turned out to be a lengthy one. Never, ever suggest on the records that something may be a quick job!!!

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Evelyn Barbour-Hill — Thu, 01 Sep 2022 01:54:14 GMT

I'm not generally one to stick my oar in when a question has already been adequately answered, but I feel I have to add my voice.

As Norman says, "just monitor" is not an option, Norman has pointed out one reason and Rachel another. I'd add that the subgingival defect will give rise to persistent periodontal disease, and the exposed dentine surface wiill harbour loads of plaque (an calculus later) I'm sorry, Clive, but I think you are wrong here.

As Rachel has indicated, you need to investigate this tooth as much as you can before finally deciding on the best treatment. Use of a probe and a sharp explorer (under GA of course!) and radiography are needed. Could you tell us the age and breed of this dog? Both could be important.

From the photo it looks as if the pulp is not quite literally exposed. However, as Rachel says,even if that is the case, pulpitis and pulp necrosis likely following this sort of "close shave". Also, any kind of treatment to restore the tooth and so protect the pulp will quite probably result in actual pulp exposure right up at the top of the cusp there.

Also as Rachel says, the contour of the deep fracture edge below the gum line is important. Very often, the edge of the fracture is (not surprisingly considering mechanics) just at the margin of the bony alveolus. If the tooth is to be restored, some sort of gum-tooth seal has got to be re-established. The original contour of the tooth at and below gum level can be restored – with some difficulty – but there may still remain a periodontal problem.

Considering the pulp, I'd treat this exactly as I would a recent actual pulp exposure. (Others may differ). However if this is a youngish dog, there is a chance it could be treated by vital pulpectomy and pulp capping, rather than full pulp extirpation ("a root canal" as it is popularly known). The advantage of the vital pulpectomy is that it would be a much simpler and quicker procedure in this 3-rooted tooth. It's not often indicated or possible in this site, so I can't give you any data, only the anecdote that the one I have done in this site was successful.

Extraction is of course a possibility, just as is amputation of a badly broken leg. But it definitely is not the easy option nor an inexpensive one. I don't want to upset anyone, but I think people resort to extraction much too readily – and then maybe find it's a wish-I'd-never-started job...

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Norman Johnston — Wed, 31 Aug 2022 20:58:21 GMT

I’m with Rachel on this but leaving it is not an option. This tooth is jagged and sharp. It will cause severe and persistent damage to the overlying mucosa. In itself that’s a reason to treat without considering the pulp

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Clive Ansell — Wed, 31 Aug 2022 20:14:34 GMT

In first opinion practice the usual options would be

1. Monitor, it may be fine and never need treatment. although doubtful in this case. There may be pain from the initial trauma, but beyond that if any treatment is needed it will likely need extraction.

2. Extraction

3. Dental referral.

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Aly Malcolm — Wed, 31 Aug 2022 11:54:18 GMT

Thank you so much for your prompt answer

RE: Help with chipped carnassial please! This tooth appears to have chipped off enamel, you can see the pulp but it doesn’t appear actually exposed, please can I have opinions on best course of action. On NSAIDS

Rachel Perry — Wed, 31 Aug 2022 11:26:12 GMT

Did you examine under anaesthesia? The fracture extends exceptionally close to the pulp if you can see it like that so there’s a high chance of pulpitis and subsequent necrosis. You could refer to a dentist for possible root canal therapy (depending on age- how old is the dog?) or you may want to consider extraction . There is a sub-gingival component, so depending on how far this extends, root canal therapy may not be indicated/sensible