Alternatives to Extractions
World Small Animal Veterinary Association World Congress Proceedings, 2007
Mary Hernandez, DVM
Riverview, FL, USA

In certain situations, tooth extraction should be considered as a treatment option but another choice can be offered. We will briefly discuss endodontic, periodontic, and orthodontic treatment options in order to avoid tooth extraction. A common oral pathology will be presented and extraction alternatives will be reviewed to give the veterinarian a fundamental knowledge of other treatment options.

Practitioners diagnosing fractured teeth with pulpal exposure should always offer referral for endodontic therapy. A strategic tooth (canine or carnassial) with a healthy periodontium should be salvaged rather than extracted. Standard root canal therapy performed by a veterinarian with advanced dental training will yield a high rate of endodontic success. If the tooth is deemed a good candidate for treatment, upon radiographic and oral assessment, the procedure can be completed in 1 to 2 anesthetic episodes. The root canals are accessed, the canals debrided and disinfected and subsequently filled with sealer and gutta percha. Radiographic assessment during the procedure is crucial. Once a good obturation is achieved, the canal can be sealed with several layers of restorative material. As an additional procedure, the tooth can be prepped and a cast metal crown fabricated for added protection.

Often times you find periodontal pockets during dental cleanings. When you call the owner they ask if there is anyway to "save the teeth." In periodontal cases where access to suprabony pockets >4mm is needed, an envelope flap will allow pocket curettage. This allows good visualization for removal of subgingival calculus, necrotic cementum, and fibrotic pocket epithelium. It cannot be preformed if the pocket requires osteoplasty and/or the periodontal area is large.

An intraoral radiograph is taken and probe measurements recorded. A reverse bevel incision around tooth is made to remove sulcular epithelium. The gingiva is elevated with a periosteal elevator so root surfaces can be accessed without exposing crestal alveolar bone. The tooth root is curetted until smooth and hard. The pocket is rinses with dilute chlorhexidine. Perioceutic can be placed in the periodontal pocket. The flap is reposition and sutured interdentally with simple interrupted absorbable suture. A postoperative radiograph is taken.

Postoperative care includes flushing the area twice daily with 0.12% chlorhexidine for 14 days, plaque prevention with a weekly application of a wax barrier sealant. At the 14-day recheck, tooth brushing can be demonstrated. Follow up exams are scheduled to monitor the patients oral health.

For periodontal pockets >4mm that have not responded to conservative treatment or infrabony pockets with vertical bone loss and sufficient attached gingival an internal bevel releasing flap can be performed. Keratinized tissue is repositioned apically thereby reducing pocket depth and increasing gingival attachment. Owners must commit to aggressive home care and frequent oral examinations under anesthesia.

An intraoral radiograph is taken. A reverse bevel incision starting at the line angle of the healthy tooth is made. Leave pocket epithelium and a thin collar of marginal tissue starting and ending at healthy gingiva. A scalloped incision is made following the contour of the roots. Vertical releasing incisions may be needed to permit better access to the tooth root and alveolar bone. Elevate a gingival flap with a periosteal elevator exposing the crestal alveolar bone and root surface(s) associated with the pocket. Remove the collar of marginal tissue and root plane exposed root surfaces until smooth. Osteoplasty, smoothing the alveolar surface, is performed with a diamond bur on a high-speed hand piece. The area is then rinsed with dilute chlorhexidine and the flap repositioned and sutured interdentally. A postoperative intraoral radiograph should be taken.

Postoperative care should include flushing the area twice daily with 0.12% chlorhexidine for 14 days and plaque prevention with a weekly application of a wax barrier sealant. At the 14-day recheck, tooth brushing can be demonstrated. Follow up exams are scheduled to monitor the patients oral health. A follow up examination under anesthesia will be needed in 3 months. During the evaluation the teeth will be probed and radiographed.

How often do you see retained deciduous canines? The class one malocclusion, known as base narrow canines can cause trauma to the palate. This condition can be seen in patients with retained deciduous canine teeth causing the permanent mandibular canine to erupt lingually. Remember that two teeth of the same kind cannot occupy the same space at the same time--in other words the deciduous and permanent canines should not be present in the mouth at the same time. Careful extraction of the deciduous tooth is recommended as soon as it's discovered. If the permanent mandibular canine is only slightly lingual and the diastema between the maxillary lateral incisor and the maxillary canine is normal, orthodontic movement can be attempted with a rubber ball. The ball must just fit between the mandibular canines, so when the dog holds the ball, the teeth are directed laterally.

If a base narrow canine is poking into the palate because of an extreme lingual eruption, refer the patient for an incline plane. The custom made acrylic incline will guide the lingual tooth into the correct position. Patient acceptance and owner satisfaction tend to be extremely high.

These are just a few common scenarios that you may encounter in general practice. With this new knowledge, consider options besides extractions when appropriate.

References

1.  Gorrel C. Veterinary Dentistry for the General Practitioner. Edinburgh: Saunders, 2004.

2.  Wiggs RB, Lobprise HB, eds. Veterinary Dentistry: Principles & Practice. Philadelphia: Lippincott-Raven, 1997.

3.  Holmstrom SE, Frost P, Eisner ER. Veterinary Dental Techniques for the Small Animal Practitioner 3rd Edition. Philadelphia: WB Saunders Company, 2004.

4.  Verhaert L. A Removable Orthodontic Device for the Treatment of Lingually Displaced Mandibular Canine Teeth in Young Dogs. J Vet Dent 16(2); 69-75, 1999.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Mary Hernandez, DVM
University of Florida, College of Veterinary Medicine
Florida, USA


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