Donald H. DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
The Mission of the Centers for Oral Care is best described in
the three words:
RECOGNITION, COMMUNICATION, and RESOLUTION.
Recognition centers on an accurate history and a definitive diagnosis. The client, referring veterinarian, and the dentist must share an accurate history to fully understant if and/or what oral problem exists. Diagnosis is confirmed with Isoflurane anesthesia, a detailed intraoral exam with probing, and dental intraoral x-ray.
Without communication, the diagnosis is meaningless. A descripiton of test findings as well as a treatment plan, with all potential options, must be made available for a decision on care to be initiated. This communication is not only authorization to proceed with a dental procedure but also a clear understanding of what is involved in the follow-up care after the procedure is performed. Supportive periodontal therapy, x-ray follow-up appointments, homecare counseling, medication necessity, and recheck frequency are just a few of areas that must be discussed in detail.
Resolution is not the completion of the procedure. Resolution is a much more complex term in referral dentistry. It encompasses all of those areas which lead to a pain free state with a quality of life for the patient. Resolution is never reached without recognition and communication. Resolution means compassion, concern, thoroughness, and comprehensive reevaluation in all areas and all intradisciplines of dentistry. Root canal therapy without addressing the needs of periodontal care is meaningless. Crown treatment of a compromised tooth is useless without detailed endodontic and periodontal diagnostics. Orthodontia without understanding the client’s or patient’s acceptance of care is without saying impractical. Resolution entails quality nursing at the dental center and quality nursing post-care when returning home.
Through the daily attention to Recognition, Communication, and Resolution, The Centers for Oral Care team challenges all problem and conditions leading to a successful conclusion with a pain-free patient.
Dental x-rays are essential to all areas of veterinary dentistry. No diagnosis can be substantiated and no treatment plan initiated or evaluated without dental x-ray.
Some common usages of dental x-ray:
- Diagnosis, grading, and evaluation of periodontal disease
- Root canal therapy
- Fracture repair and oral orthopedics
- Pedodontics–problems with immature dentition
- Feline Stomatitis and erosive carie diagnosis and treatment
- Oral surgery, both pre and post care
- Pre and post crown treatment of fractured teeth
- Restorative dentistry
- Oral pathology diagnostics
- All breed– health exams in Pedodontics; Especially in pre-purchase of mature Guard, Police and Schutzhund canines
Radiosurgery (see www.radiowaveradiosurgery.com)
For increased patient comfort and decreased anesthesia time, Dr. DeForge utilizes radiosurgery in the department of periodontics, oral surgery, and prosthodontics. Radiosurgery utilized the passage of high frequency radiowaves through tissues for the purpose of cutting and coagulation.
A pressure free incision with rapid site exposure allows immediate approach to areas of pathology and/or treatment while allowing ease in closure when completed. These characteristics allow the patient a greater comfort zone upon leaving the operatory.
Common uses of radiosurgery in veterinary dentistry are:
- Exposing subgingival decay
- Incisional and excisional biopsy of soft tissue in the oral cavity
- Periodontal flap surgery
- Crown preparation with resultant impression excellence
- Troughing for crown cementation
- Treatment planning in Feline Stomatitis
The department of periodontics addresses the concept of animal preventive dentistry through professional periodontal care and individualized home care programs. Periodontal care does not mean crown scaling alone. It includes a complete extraoral and intraoral examination, probing with periodontal grading, root planing and diagnostic dental intraoral radiology (ie. dental x-rays) as indicated.
Exam room scaling of teeth is ineffective and non-productive. The use of tranquilizers and injectable sedatives is not recommended in diagnosing and/or treating periodontal disease. These drugs, although fine for other procedures, are contraindicated in veterinary dentistry because they do not provide a safe, pain-free state for oral care. Sevoflurane or Isoflurane are the recommended inhalation anesthetics for these procedure. They are as safe as nitrous oxide used daily in human dental practices around the world to relieve anxiety and pain. For dental x-ray diagnostics, probing, root planing, and professional care, Sevoflurane or Isoflurane are the inhalation anesthetics of choice. The patient must be able to be worked on in a state without unnecessary movement that could cause injury. These anesthetics provide an excellent safety net for ALL BREEDS!
Prior to the usage of Isoflurane or Sevoflurane gas inhalation anesthesia, it is very important that all patients have individualized pre-anesthetic testing based on age, medical history, and general health at the time of examination. Pre-anesthetic testing is an important part of the anesthetic protocol. As stated, Sevoflurane or Isoflurane gas anesthetics are very safe as long as the patient’s pre-testing medical profile is complete.
Exodontia is the term used to describe the removal of teeth. Certain teeth cannot be treated with root canal therapy because the disease process is too advanced. Other individuals will not want root canal therapy but seek tooth removal. At the Centers for Oral care, no teeth are removed without client consent.
The option to save a tooth is always first presented. With refusal, teeth can be removed. Extraction are never completed without pre and post extraction x-ray. This is important in developing the best plan for removal and to prevent damage to the already compromised bony structures surrounding the abnormal tooth. The x-ray allows a careful examination of the diseased tooth roots and adjoining tooth roots. This same radiology exam lets the veterinary dentist know whether the disease process has spread to other dentition that may also need extraction.
Dr. DeForge’s plan for exodontia includes the following:
- Pre-treatment radiology
- Full thickness mucoperiosteal flap surgery
- Alveoplasty of pathologic bone and osteomyelitic bony spicules
- Bone graft placement
- Suturing of all flaps with absorbable suture
- Post-extraction radiology
- Post surgical home care counseling
- Periodontal counseling of all remaining dentition
- Six month follow-up bone graft radiology
- Six month post-op periodotnal grading
Gingivitis is a reversible form of periodontal disease: it includes inflammation of the gingiva, swollen gingival margins, gingival bleeding with light pressure, and in many cases halitosis. No radiographic changes of bone loss are noted.
Periodontitis is an irreversible form of periodontal disease. With periodontitis there is deep inflammation of soft tissues (i.e. gingiva and oral mucosa), loss of bony support, and abnormal radiographic findings. Even though periodontitis is irreversible, it can be controlled with dental intervention and immediate treatment. This leads to a patient with a quality and pain free oral condition. The progression of the disease is halted and no unnecessary oral surgery, after initial care, will be needed if professional monitoring and exceptional home care is balanced.
Many times gingival hyperplasia, gingival recession, and tooth extrusion are present at this time. On intraoral dental x-ray, horizontal, oblique, or vertical bone loss can be found. A detailed intraoral examination is essential in this advanced form of periodontal disease. All breeds, and especially small or toy breeds, four years of age or older that have never had oral care are prone to advanced periodontal disease.
You can begin you own oral exam at home and have it verified by your veterinarian or by a veterinary dentist trained in oral care. Begin by checking the mouth for fractured teeth. Examine the mouth for worn teeth (i.e. attrition) with open pulp canals (black or brown dots on the chewing surface of posterior teeth or on the lifting and holding surfaces of the incisors or cuspids. These are “red flags” for immediate dental x-ray. Call your veterinarian for an oral exam and dental x-rays. Your veterinarian will examine by dental x-ray teeth with enamel fractures or dentin exposure on the crown or root. They will x-ray and refer you to a veterinary dentist if there are open pulp canals for root canal therapy rather than extraction. Dental x-ray will allow your doctor to examine the root apex of teeth with advanced periodontal pathology. Many of these will need combined endodontic and periodontal care. Dental x-ray is the key. For more information on dental x-ray please refer to:
An Atlas of Veterinary Dental Radiology (Second Edition, 2008)
Editors: D.H. DeForge, VMD
Printed by Sheridan Books, Inc./ composed by Brooklyn BookWorks, LLC
Prosthodontics in veterinary dentistry refers most often to full jacket crown coverage. Crowns or caps are not for cosmetic or aesthetic primary care in animal dentistry. Crowns help protect the traumatized natural tooth structure. They can be utilized in conjunction with root canal therapy or in vital teeth for protective purposes. The most common crown material is Titanium alloy in animals. Other crown materials are non-precious gold, white gold, Inceram, and ceramic (filled polymers). Inceram and ceramic polymers can be shaded to natural tooth color. Call or email Dr. DeForge about the options and treatment plans for each of these materials.
The veterinary dentist uses the following tools to define, diagnose, and set-up treatment plans with oral growths:
- Intraoral examination with dental x-ray
- Standard x-ray for specific sites
- Histopathologist, Oncologist, and Radiologist consultations
To determine if an oral growth is benign or malignant can be straight forward or require a team of specialists. It is imperative that any patient referred for cancer screening have a complete medical work-up from the referring veterinarian including:
- Chemistry Panel and CBC
- Chest and Abdominal Radiology
- Echocardiography- depending on cardiac exam and age
- Abdominal ultrasound imagine-depending on survey films of abdomen
If this work-up cannot be completed, contact Dr. DeForge for an appointment with an internal medicine specialist to accomplish this evaluation.
Oral Trauma Care
Veterinary dentists are called upon to help in many trauma care condition.
Common sites of treatment are:
- Fractured mandibles and maxillae
- TMJ dislocations
- Tooth Subluxations and Luxations
- Tooth avulsions
- Mandibular Symphysis separation
These conditions caused by baseball bats, rock catching, “high rise” falls or jumps by cats, auto accidents animal fighting, and a slew of other causes. They are all reparable if seen close to the time of an accident. If a tooth is dislodges or completely avulsed (i.e. removed from its socket/alveolus), put the tooth in a clean jar in a milk bath and call you veterinary dentist immediately. These teeth can be replaced. Many timed root canal therapy will be necessary in 30-120 days post re-implantation. With the new splinting techniques, dental radiology, and an understanding of endodontic complications, there is a great window of success in tooth re-implantation.