Your Pet's Best Friend

Bad breath is not always bad teeth.

It could be kidney failure, it could be advanced diabetes, it could simply be that your pet has eaten something that smells really bad... poop, for instance.

And then there are those unexpected things.  Pepper was in for a check-up in September.  I talked with the owner about the accumulation of dental tartar, and how that's a bad thing.  "Well, you just cleaned them recently."  Time flies -- it was over two years ago. "Well, I'll think about it."  [This actually means "No; and after I leave here, I won't be thinking about it."]

Then, in the past couple of weeks, Pepper began to develop really bad breath.  This forced his mom to make good on her promise to "...think about it."  The more stinky he got, the more she thought about it.  Finally she thought about it enough to decide to get his teeth cleaned.

And this is what I found.  Yes, he had a lot of tartar on his teeth (I didn't make that up in September), but that wasn't where most of the stinkiness was coming from.   This heavy thread was looped around an incisor tooth (#102 for you dental types) and he was trying to swallow the rest of it.  It was accumulating hair, bacteria, and assorted ooey-gooey.  It did stink (probably still does, if I were to fish it out of the trash). Since it was hooked on to his tooth, he couldn't really swallow it.  Part of it was in his mouth, part was in his esophagus.

It's fairly long, and it had damaged the gums pretty badly around the tooth.  The tooth was getting loose, so much so that I had to just extract it.  I guess he might have eventually swallowed the whole mess when the tooth finally came out, but then he could have developed an intestinal obstruction from the string (the old "linear foreign body").  That's the tooth there on the left (look closely).

This is the part that really bothers me.  The string was sawing back and forth all the time, eroding a groove in the roof of Pepper's mouth. Man, don't you know that feels better now? 

And don't go criticizing Pepper's owner.  If he wasn't such an uncooperative little mutt, she would have been brushing his teeth, and noticing the string, and taking it out.  Unfortunately, with this boy awake, it's hard to get a good look in his mouth.  In fact, it's hard to get your finger back in one piece. 

All's well that ends well... until our next episode.

Abscessed teeth don't look like this.

So, do you remember in the "Addams Family" movie when little Wednesday is going to be a serial killer for Halloween?  She wears her regular clothes as a costume because "They look just like everybody else."  That's the way that abscessed teeth usually look.  You can't see any difference between the diseased tooth and the normal teeth without an X-ray.  Even when something is draining, you can't be sure which tooth's root is problem.  The draining tract could be crooked.

We were just supposed to clean this cat's teeth because it had bad breath and visible tartar.  The owner had no idea that the cat was in any pain.  She was eating fine, acting "normal".

So I opened her mouth to clean her teeth, and something looks funny around her right upper canine tooth (#104 for you dental types).  The gums are swollen and there's a red spot.

Hey, take a look at that red spot.  Push on the gums and stuff oozes out.  That is so cool.  When I probe under the gum-line, much more stuff gooshes out [ goosh = Southeast Missouri for "gush"].  The tooth is NOT difficult to extract.

Here's the tooth and, in addition to being all raggedy-looking instead of smooth, there's no pink stuff stuck to it.  That's why it was easy to extract -- pink stuff means it was attached to the socket.  In this case there was pus between tooth and socket.

Gosh, I wish all abcessed teeth were like this, but they are not.  That's why we need those dental X-rays, folks.  How many abscessed teeth are out there hiding for every obvious one like this one?  Hard to say.  In thirty years, I've only seen a couple of obvious ones like this, so I'm guessing that there are a lot of incognito abscesses out there.

I hate for him to lose a tooth.

"And I'm afraid to have him anesthetized.  I'm afraid something will happen."

Hey, something did happen.  This tooth lost its attachments and was hanging by a thread, which makes it wiggle around and hurt.  It wasn't much trouble to extract this one.  The tooth ought to be the color of those two white roots, not covered wtih brown crud.  That pink dot was the only remaining attachment.  The teeth he has left are similarly encrusted with tartar.  Some of them are probably in about the same shape, but the tartar is bridging them to the next tooth so they don't wiggle so much.

Now that I've flipped this one out of the poor dog's mouth, they are going to have another family talk about getting his mouth situation handled. [Six months ago, I didn't convince them.]

Feline Leukemia Virus and Dental Problems

Blue Kitty is a "stray".  He's been living at the same place for months, and they like him, and they feed him, but... he's pretty independent.  Not the kind of cat that wants to come in and sit on your lap.  Really, he's about half wild.   Under those circumstances, he doesn't exactly get a thorough physical exam every day.  In the last couple of days, they noticed that he just wasn't himself, just eating a little bit.   That's why they scooped him into the carrier and brought him in.

Really, he's more than half wild.  His goofy expression  here is due to the fact that he had to be sedated to handle him, much less do any kind of real examination.  He's messed up on dope.  He's messed up on a bunch of other stuff, too.  He's pretty thin, about 20% underweight (which is a lot) and about 5% dehydrated.  He's been feeling bad for more than just two days; at least, he's been in ADR mode ["Ain't Doin' Right"] for longer than that.

He really stinks, too, and this mouth is why.  Not only is there a lot of tartar, his gums are oozing pus and blood around almost every tooth.  When you see a cat with such terrible gum disease and some major ADR, you have to wonder if this guy has a normal body defense system.  I mean, there HAS to be a reason when somebody looks like this.  This is beyond mere dental hygiene problems.

And here you have his little SNAP test.  The blue spot on top is the positive "control" that lets you know the test is working properly, and the blue spot on the right is the one that lets you know Blue Kitty's blood is full of Feline Leukemia Virus.  Few cats get the actual leukemia that gives the virus its name.  Most just have their immune system shot to hell, like a person with HIV and AIDS.  Then they sort of waste away, or start to have a lot of weird infections that shouldn't really be bothering them, like Blue Kitty's mouth problem.

Prognosis: poor.  That's why you run this test before you advise the client to jump in with both feet, guns blazing and checkbook open wide.  They need to know that you may be able to help the cat, but he's not going to get "well".  Tough break for the cat who wound up in a high-risk lifestyle.

Look in your pet's mouth once in a while.

"So, how long has that tooth been broken?"  Replies range from "Huh?" to "I didn't know he had a broken tooth." to "A long time.  I don't think it bothers him."   I must confess that I don't have the moral high ground, here.  I pet the dog, I feed the dog, I don't give the dog a thorough physical exam every day.  With a cat, most people are even less likely to do so, given a cat's serious consideration of his own dignity and right to privacy.  Tom (pictured here) came in for an unrelated problem, but stayed to get this painful problem handled.

Most people who don't think it bothers the animal just haven't given it much thought.  This is Sadie, and she was just in for her normal checkup.  Her owner hadn't noticed much of anything bothering her.  She answered in the negative to the standard yearly physical exam catch-all question, "Are there any problems you've noticed or been concerned about?"

Here's the first thing I noticed in her mouth.  Mom hadn't seen it, and it is obviously not "fresh".  "Have you noticed her having any trouble eating?  Favoring one side?"  Nope, haven't noticed.  Once again, I don't get to keep the oral moral high ground, because, having found this broken tooth and convinced the owner we need to take care of it, I wasn't as careful in the rest of my examination.  Hey, we'll catch anything else when we anesthetize the dog to extract this tooth and clean the rest.

This is what I found when I cleaned the teeth.  This tooth was the only tooth in the mouth that was covered with tartar, but I didn't pay much attention to that during the original exam.  Why is that one tooth covered with tartar?  Because she doesn't chew anything with it, that's why.  When the tartar came off, the pulp chamber immediately began to bleed where the side of the tooth had been fractured off.  How long ago?   Long enough to crust over with tartar. 

Interestingly, when I called the owner to give her the news, she told me she had been watching Sadie since we found that little broken tooth in front.  Sure enough, she only chews on her left side (not this one), and really, she doesn't show much interest in chew-bones anymore. 

After getting these painful situations handled, I have high hopes that Sadie will be chewing normally again.  Note to self:  look in dog's mouth tonight.

Nasty teeth need to come out.

Many times we are presented with a pet whose teeth are terribly diseased.  They have lost most of their attachment to the jaw, and the gums are swollen, infected and bleeding.  Amazingly, after neglecting the pet's mouth to this condition, some owners are distressed because "You pulled his teeth." 

Teeth like these are the dental equivalent of "dead man walking".   They can't get back to normal, and can bring the pet nothing but pain.  They have GOT to come out.  What prompted me to post was a new analogy that I'm going to try out.  We're always looking for a way to make the pet's dental problem more real to the owner.

Shannon walked by and I asked if she'd put one of those nasty things in her mouth.  She didn't curse much and she didn't hit me very hard.  I said, "Hey, the dog had those in her mouth all the time."

Well, maybe that's just too gross.  Sorry about that, chief.

More retained baby teeth.

Last summer I did a short post on a kid with 10 retained baby teeth.  What a piker.

This is Abby.  She's not showing you much of her smile. At this point, you wouldn't have minded seeing it, but you surely wouldn't have wanted to smell it.  She has a lot of baby teeth that failed to move on when the time came.  She's a little bit of a late bloomer.  At nine months old, not only has she not shed all the deciduous teeth, but her permanent canine teeth look like they are not quite fully erupted.

The reason you wouldn't have wanted to smell her breath is that all these extra teeth are pretty bad about catching a lot of junk.  She had wads of thread and hair jammed between the over-crowded teeth.  Some teeth are coming in crooked.  There's gum disease, and a suprising amount of calculus (tartar) accumulation, considering that she's only nine months old.

Here are FIFTEEN baby teeth that should have come out on their own.  Three of them were just crown-caps with the roots dissolved, but they were still in place, and still trapping crud.  The tooth with bloody roots at "10 o'clock" is the opposite number to the little cap at "2 o'clock".  It was pretty solid, but it had one bad root, and was crowding three other teeth.  It left a big enough hole that we had to suture it.  That's a little unusual for a baby tooth.

  Here's part of Abby's new smile with a normal number of teeth.  Her mom is committed to keeping her in shape, and I'll bet that her smile just gets better. I don't think she'll ever end up like this dog.

Severe dental problems are not always obvious.

This is Tommy.  He came in to get a skin problem checked out.  Since a skin problem is sometimes just "the part you can see" of a whole-body problem, we always do a complete physical examination.  In checking Tommy's teeth, I found that his left upper cheek tooth was the wrong shape, covered with tartar, and loose.  "Well, you know, he hasn't wanted hard food for quite a while.  He will only eat soft food.  He doesn't act like he's in pain, though.  He still jumps and plays."   Gee, I think that if he's got a broken tooth wiggling around in his mouth, it probably does hurt.  Why don't we take care of that, and clean up the rest of them while we're at it? "Well...yeah!"  So we did.

The little chunk on the left is what I was wiggling around during the exam.  It came out easily, didn't even leave much of a hole (though we did stitch it closed).  The tooth on the right was more of surprise.  When we cleaned off all the tartar that was covering it up, it just didn't look right.  It looked like...half a tooth.  What's worse than finding a worm in your apple?  That's right: finding half a worm in your apple.

Here's a different view.  You can see the split surface with the open pulp cavity.  Ouch!  Isn't it amazing that "the cat doesn't act like he's in pain"?  For a moment, imagine yourself biting down on something that splits a molar tooth in half, leaving the open pulp exposed.  Imagine not being able to do anything about it for months.  You don't even want to imagine it, do you?  Now, imagine yourself pretending that... it doesn't hurt!  Good luck with that.

So now those teeth are out, the socket is filled with Consil synthetic bone graft, and the holes are sewn shut, and lots of nice pain medicine has gone home with Tommy.  I'm looking forward to hearing about his return to eating whatever he wants, and to the surprising improvement in his behavior (the kind you get when constant pain goes away, as in a previous post).

He is NOT too old to get his teeth cleaned.

This "Beau".  He is thirteen years old, and this picture was taken about 15 minutes after we finished cleaning his teeth.  His teeth were really covered with calculus (tartar), and he had a little gum disease.  Cleaning his teeth was especially important because of his other medical problems.  Not his lower back problems (which have been really bad at times), and not his low thyroid condition (for which he takes medicine twice day), but because he has severe heart problems. 

Beau has congestive heart disease.  He has been on twice-daily medications for four years.  You may not have looked at many chest X-rays, but take my word for it:  this is a big heart.  It looks like a basketball, double the size it ought to be.  It's not big and strong, either.  It's stretched out of shape and weak and flabby.  His cardiac output when he's wide awake is worse than most dogs while they are under anesthesia.  SO... who's up for knocking him out to clean his teeth?  [I can't hear you.]

Anything you do involves making a decision as to whether the risks outweigh the benefits.  When they dropped off Beau, the last thing the owners said was, "Don't kill him."  Hey, no pressure.

First the Benefits: clean teeth, fresh breath, healthy gums... so what?  Just don't look at his mouth and you can pretend he has all those.  Then there's the fact that you get rid of the zillions of bacteria that his mouth is constantly dumping into his bloodstream -- bacteria that are clogging up his kidneys and damaging them, and that would love to colonize his damaged heart valves.  Okay, that's a little harder to ignore.

What about the Risks?  Well, he's thirteen years old and has had heart disease for four years and he might die with clean teeth.  We could have stopped right there, but we didn't.  We decided to look at his actual risks.  First, his bloodwork is good -- no problems with liver or kidney function.  Second, if you look at that chest X-ray again, you'll see that the lungs are clear -- no fluid and looking good.  Third, his electrocardiogram got a pass from the cardiologist at Idexx telemedicine.  So...a lot of his "risk factors" are actually not so risky.

We put Beau on I.V. fluids and kept his anesthesia light (with easy-to-adjust Sevoflurane gas), monitored him closely, and I worked at a furious pace.  My receptionist wandered back to see how we were doing and said, "Your next appointment has cancelled, so you can take your time."  Wrong.  No matter how good his labwork was, there's no point in pushing our luck with that big, weak heart.

The point of the post is this:  you folks with your 9-year old dogs with healthy hearts have got to stop using the "he's too old" excuse for not getting those mouth problems handled.

My First Orthodontic Appliance

Well, not actually my first braces or retainer (that was 44 years ago, after all).  I mean the first one that I've applied to a patient.  In a previous post we talked about how retained baby teeth can lead to malocclusion: teeth that grow in where they don't belong.  On little Cocoa here, I failed to get a good "before" picture of that (before I did anything, that is).

This is a "before picture" as far as the teeth are concerned.  The white blob is the acrylic appliance I built up in the roof of Cocoa's mouth.  You can't see the  grooves that are cut in the wedge sticking down, but they are there.  What you can see are that the lower canine teeth (bottom fangs) are coming straight up so that they were hitting the roof of the mouth.  See how straight up and down they are?  They should have been angled out to wind up between the upper teeth.  As Cocoa closes her mouth, those teeth encounter the wedge now, and the grooves direct her teeth outward.

Here's a side view, showing the acrylic blob that covers part of the roof of her mouth, anchored to her upper teeth.  It's pretty thick in this picture.  After two weeks, the teeth had moved enough that the wedge wasn't hitting her teeth anymore, but was hitting the bottom jaw.  We shaved the blob down and cut new grooves to direct her teeth.  I was in a hurry that day, and didn't make time to get pictures of stage two, unfortunately.

Here she is at four weeks, minus her appliance (i.e. blob of acrylic plastic).  You can see that the lower fang is now directed outside her upper teeth and into the groove where it belongs.  This is pretty cool, and much less uncomfortable than having her bottom fangs poking her in the palate.  I'm glad I got the chance to do it, but if I'd gotten the chance to extract those funky baby teeth back in March, Cocoa wouldn't have needed this repair.

Watch out for those baby teeth when the permanent teeth come in.  If they aren't getting loose by the time the permanent tooth is halfway in, it's time for a visit to your veterinarian.