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Dental extractions: Leave 'em, take 'em , hold 'em or fold 'em?
When is dental extraction the treatment of choice? Find out in this first installment of a multipart series on what to do to when faced with dental pathology.
The foremost dental decision made daily is whether to leave teeth with suspected pathology to follow up in the future, treat the teeth or extract them. For some teeth the decision is easy, especially if they are mobile. In other situations, having a goal of creating a pain-free mouth that is functional will help you make correct choices. This is the first installment of a series to help you decide how to deliver the best in dental care by extracting teeth. The next installment will cover how to treat what you see, and after that we'll discuss when it's best to do nothing and follow up in the future.
We need to be our patients' advocates when extraction is indicated. Most clients will not realize their pets are in pain because that pain is masked. In essence, we are doing harm when we do not urge our clients to let us care for painful dental problems. When a client asks, “How will my dog eat after its teeth are extracted?” it's best to respond, “Better than before because we are removing the oral pain.” Most clients see a great improvement in their pets' lives within weeks of extractions.
Is the patient's bite functional or poorly functional?
A scissors bite where the maxillary incisors lie just in front of the mandibular incisors and the premolars interdigitate allows the teeth to work in an efficient, or a functional, manner. When teeth are in abnormal locations due to inherited defects or previous trauma, often an inefficient, or a poorly functional, bite results.
Generally, any time there is a problem with a deciduous tooth, it should be extracted. This includes retention next to the adult tooth, malposition and fracture exposing the pulp (Figures 1A, 1B and 1C).
Figure 1A. A retained deciduous maxillary canine and malpositioned third incisor tooth. (All photos courtesy of Dr. Jan Bellows)
Figure 1B. A malpositioned deciduous canine tooth impinging the maxillary gingiva.
Figure 1C. Fractured mandibular deciduous canine teeth penetrating the maxillary gingiva.
When the adult mandibular canines and incisors impinge or penetrate the maxillary gingiva, extraction or crown reduction and restoration relieves discomfort and creates a functional bite (Figures 2A, 2B and 2C).
Figure 2A. Mandibular distoclusion resulting in impingement and penetration by the mandibular canines and incisors on the maxillary gingiva.
Figure 2B. The extracted mandibular canines and incisors.
Figure 2C. Extraction of the mandibular canines and incisors, resulting in a functional, pain-free bite.
Conversely, when the maxillary incisors impinge or penetrate the mandibular gingiva, extraction of the maxillary incisors creates a comfortable occlusion (Figures 3A and 3B).
Figure 3A. Retained deciduous canines and mandibular mesioclusion where the maxillary incisors are impinging on the mandibular gingiva.
Figure 3B. One week after surgical extraction of the deciduous canines and maxillary incisors, the impingement has been eliminated.
When teeth are too close together or extra teeth are present, creating crowding, extraction will often relieve or prevent periodontal inflammation and pain (Figures 4A and 4B).
Figure 4A. Malpositioned maxillary and mandibular incisors resulting in crowded teeth prone to periodontal disease.
Figure 4B. Resolution of crowding after multiple incisors were extracted.
Should I extract or leave fractured teeth and teeth affected by advanced periodontal disease?
Visible signs. How do you decide if you do not have intraoral radiography? Look for obvious signs of pathology caused by endodontic disease, including pulpal exposure with clinical focal swelling of the face or the alveolar mucosa above the mucogingival line. If the client will not accept referral to a veterinary dentist for advanced endodontic care, extraction is indicated (Figures 5A and 5B).
Figure 5A. A complicated crown fracture of the maxillary fourth premolar (green arrow) and swelling above the mucogingival line (yellow arrows).
Figure 5B. A draining fistula apical to the left maxillary first molar secondary to a complicated crown fracture.
Probing abnormalities. The dental probe is a valuable instrument that can be used in every oral assessment performed under anesthesia. Small dogs and cats should not have probing depths greater than 2 mm, while larger dogs normally display 4-mm depths around the canines and 1- to 2-mm depths around the incisors, premolars and molars. When the probing depths are greater than 5 mm, surgery is indicated in the form of either open root planing or extraction (Figure 6).
Figure 6. A palatal 12-mm probing depth in a dachshund, necessitating extraction.
Tooth mobility. Fractured teeth that are significantly mobile due to advanced periodontal disease or root fracture need to be extracted. But these extractions may be a challenge without intraoral radiographs.
How do intraoral radiographs help?
Intraoral radiographs aid the decision-making process whether to leave, treat or extract an endodontically affected tooth. When referral to a veterinary dentist is not in the cards, those teeth affected by internal resorption where the root canal is not only enlarged but nonuniform compared with the contralateral tooth should be extracted along with those teeth that have marked periapical lucency (Figures 7A and 7B).
Figure 7A. An intraoral radiograph of the right mandibular fourth premolar and first and second molars affected by endodontic and advanced periodontal disease. Extraction of all three teeth is indicated.
Figure 7B. A postoperative radiograph confirming complete extractions of the affected teeth. The third premolar appears normal.
When should I extract resorbing teeth?
In cats and dogs, resorbing teeth with pathology extending into the oral cavity should be extracted together with those with marked loss of dental hard tissue. When the tooth resorption extends into the oral cavity, bacteria will gain access into the tooth, causing inflammation necessitating extraction (Figures 8A, 8B, 8C and 8D).
Figure 8A. Stage 3 tooth resorption in a cat's maxillary third premolar.
Figure 8B. Tooth resorption of a cat's maxillary fourth premolar (arrows) necessitating extraction.
Figure 8C. Tooth resorption in a dog's left mandibular first molar.
Figure 8D. An intraoral radiograph of marked root resorption in a dog's third and fourth mandibular premolars with extension into the oral cavity. Extraction is indicated.
When should all the teeth be extracted?
Marked chronic stomatitis is thought to be caused by a hyperimmune response to plaque. Full-mouth extraction eliminates the dental plaque-retentive surfaces, eliminating or at least decreasing inflammation (Figures 9A, 9B and 9C).
Figure 9A. Mucositis affecting the gingiva surrounding the mandibular premolars in a cat.
Figure 9B. Extraction of the cat's teeth.
Figure 9C. Resolution of the stomatitis after full-mouth extraction.
Comfort vs. pain
Fortunately, the dogs and cats we see in companion animal practice do not need their teeth to survive. They do not have to depend on their teeth to kill prey. For them kibbled, canned or soft human food is delivered to a bowl once or twice a day. Our dental goal is to provide a healthy, functional and pain-free mouth. Often and for good reasons extraction is the treatment of choice.
Dr. Jan Bellows owns All Pets Dental in Weston, Florida. He is a diplomate of the American Veterinary Dental College and the American Board of Veterinary Practitioners. He can be reached at (954) 349-5800; email: firstname.lastname@example.org.