Dentistry case study

Canine Dentistry

Dental Case Study

1

Trina Mullan 6986 Words

19/10/2015

Abstract

The Canine was admitted for a scale and polish but once under anaesthetic the Veterinarian noticed there was gingivitis

attached to a number of teeth and felt best to remove these. The patient had an easy recovery was discharged at the end of the

day.

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3

Initial Examination

History

Patient has no previous clinical history but had previously been on arthritis medication when in the previous working environment. Patient is now retired but is in overall

good health for his age.

Distance Exam

Area

Examined

Result Normal Values Variations from normal values Reasons for variations

Coat Clean, shiny Clean, shiny (Plus, Carrying out a

clinical examination, 2015)

Greasy, scruffy, dull, hair loss. (Plus, Carrying out a clinical

examination, 2015)

Illness, stress, malnourished, allergies, hormonal.

(Cooper, 2014)

Body

Condition

5 – ideal. Purina

Body Score.

See Appendix 1

5 – Ideal. (Purina, 2015)

See Appendix 1

1-4 Underweight. (Purina, 2015)

5-9 Overweight.

See appendix 1

Underfed, allergies, stress, internal or external

injuries. Overfed, hormonal. (Cooper, 2014)

Respiration

Rate and

Character

36RPM, regular 30-40RPM Regular (Lee, 2011) Tachypnoea, bradypnoea, Dyspnoea. (Plus, Carrying out a


Tachypnoea caused by

Excitement, fear, exertion, fever, pain.

Bradypnoea caused by

Poisons (narcotic or hypnotic),

metabolic alkalosis, head injuries, coma,

and sleep.

Dyspnoea caused by

respiratory obstruction

haem thorax,

pneumothorax,

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Pneumonia. (Plus, Carrying out a clinical

examination, 2015)

Posture Relaxed Relaxed, front of cage Hunched or tucked up, head down, lack of symmetry, lack of

weight bearing on a limb in the standing position, signs of

straining (Plus, Carrying out a clinical examination, 2015)

Trauma such as

road accident

fighting another animal

Gait Equal weight bearing

on all legs

Equal weight bearing on all legs

during movement.

Paresis, plegia,quadriplegia, hemiplegia,hypermentria, bow

legged

Muscular weakness caused by nerve damage or

disease.

Injuries No injuries are

present

No wounds, no cuts, no limping,

weight evenly distributed on all

four legs.

Wounds, cuts, limping, protruding bones Trauma such as

road accidents,

fighting,

Falls.

Behaviour Anxious but relaxed.

Sitting in front of

cage.

Relaxed Aroused, Total fear, defensive aggression, aggressive attack

(Plus, Canine Handling and Restraint, 2015)

Aroused, stimulated by something in

environment, happy and pleased.

Total Fear, Threatened and avoiding

physical confrontation.

Defensive Aggression, often used by

fearful canines

Aggressive attack, (Plus, Canine Handling

and Restraint, 2015)

Demeanou

r

Bright and aware. Bright and alert (Plus, Carrying

out a clinical examination, 2015)

Aware, drowsy, restless, depressed, vocalising, tics, fitting,

stuporous, non-responsiveness, comatose (Plus, Carrying out

a clinical examination, 2015)

Pain,

injured,

Nervous (Plus, Carrying out a clinical

examination, 2015)

Disposition Anxious but sitting

front of cage, tail

curled around, ears

Confident, sitting at front of

cage, will approach soliciting

attention. Ears relaxed.

Aware, drowsy, restless, depressed, vocalising, tics, fitting,

stuporous, non-responsiveness, comatose (Plus, Carrying out

a clinical examination, 2015)

Nervous or frightened

Extremely nervous or frightened

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forward. (Cooper, 2014) Aggressive/attack (Plus, Feline Handling

and Restraint, 2015)

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Approach and removal from cage

When approaching a Canine in a cage the first rule is ensure all windows and doors are closed. This prevents patient

escaping from the room/clinic. It also prevents contamination of rest of clinic. Assess temperament of Canine, this

Influences the way the patient is approached i.e. defensive aggressive patient will take more restraint than a

confident patient. Muzzles, slip leads may be needed for more aggressive patients. Restraint method varies but can

be influenced by the individual Canine and the following must be taken into account

Age

State of health

Type of injury

Nature or disposition

Environment (Plus, Canine Handling and Restraint, 2015)

In this case the patient was relaxed and showed no aggression so a quiet calm voice was used while approaching the

patient and allowing the patient to sniff the back of hand through the cage. Once door is opened the patient was

stroked under the chin and throat for reassurance that the patient will not be hurt. (Plus, Canine Handling and

Restraint, 2015)

Removal from cage

Action Justification

Talked to the patient calmly and quietly as

approached and deliberately crouching down to its

level.

Crouching low helps to prevent fear aggression. Standing

over the canine may provoke it to jump up and bite.

(Aspinall, 2014)

Placed one arm around the front of the dog’s chest

and the other around its back end.

This will prevent the canine struggling as it is lifted

(Aspinall, 2014)

Safe handling and restraint

It can be helpful to spend some time chatting to the owner of the dog before attempting to handle or approach the

dog. This can convey to the dog that the nurse is not a threat. If the patient is aggressive, a cautious approach must

be taken. The owners could put a muzzle on the Canine if aggressive behaviour was known. This could also be

recorded on patient’s notes. The owner could also assist in restraining the patient. (Plus, Canine Handling and

Restraint , 2015)

7

When possible

A dog should be encouraged to approach a nurse or vet rather than the vet or nurse directly approach the

dog

Cornering a dog, leaning over it or prolonged direct eye contact should be avoided as dog may find

threatening.

Crouching to the dogs’ level can help with nervousness but not so close that your face is within biting

distance. (Cooper, 2014)

When it comes to restraining a canine for clinical exam, place one arm under the canine’s neck and pull the head

close to your chest with your hand and place the other arm either under the abdomen or around back to pull the

canine into the handlers’ body. Sometimes it can be easier to keep the canine on the floor and back up into a corner

rather than on a table. (Aspinall, Clinical Procedures in Veterinary Nursing, 2014)

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9

Superficial Exam

Area Examined Result Normal Values Variations from normal

values

Reasons for variations from normal values

Heart rate 134 BPM 60-180 BPM (Lee,

2011)

Tachycardia, Bradycardia,

strong, weak, irregular.

(Plus, Carrying out a


Tachycardia,

Excitement, fear, exercise, pain, fever, heat, anaemia/hypoxia, hormonal

disturbances e.g. thyroid.

Bradycardia,

Unconsciousness, anaesthesia, sleep.

Weak, shock, diminished cardiac output.

Strong/irregular, valvular insufficiency, congenital heart defects (Plus, Carrying out a clinical

examination, 2015)

Eyes Clean, clear, no

discharge,

inflammation.

Both eyes open, no

squinting of the

eyelids. Both eyes

same size. No

discharge. Pupils

same size (Cooper,

2014)

Conjunctivitis, corneal

ulceration, water eyes,

glaucoma, discharge

(unilateral or bilateral),

inflammation of

conjunctiva, irritation.



Allergies, bacterial, fungi or viral infections.

Cat fights can damage or scratch eyes causing ulcers.

Inherited defects, blocked tear ducks.

Foreign bodies such as grass (Vets, n.d.)

Ears Clean, no

discharge, no

smell

Ear pinnae should

be free of

scratches, wounds

and swelling.

Vertical ear should

be free of

inflammation, wax,

Inflammation, yeasty

smell, discharge, swelling,



Black-brown discharge may indicate mites,

Brown discharge may indicate yeast infection,

Yellow discharge may indicate bacterial infection (Plus, Carrying out a clinical

examination, 2015)

Swelling on Ear pinnae can be sign of hematoma. (Cooper, 2014)

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discharge, foreign

bodies and

ectoparasites. No

odour should be

smelt (Cooper,

2014)

Nose Clean, no

discharge

Clean, no discharge Sneezing, snorting, facial

swelling, nasal discharge

(Cooper, 2014)

Nasal discharge

Viral, bacterial, fungal infections, allergies, neoplasm, foreign objects (Cooper,

2014)

Mouth Clean, no foreign

objects, no

inflammation in

lip folds, tongue,

throat.

Teeth dirty clean.

Halitosis.

No swelling,

inflammation in lip

folds. No

inflammation or

ulceration inside

mouth on tongue

or back of throat.

(Plus, Carrying out

a clinical

examination, 2015)

Swelling, inflammation of

mouth, tongue, back of

throat, foreign objects.



Infections

Gingivitis, Periodontitis, Stomatitis, rodent Ulcer, Salivary Cyst, mouth ulcers.

(ASPCA, n.d.)

Mucous

membranes

Pink Pink. Conjunctive

rectum may be

used to test

membranes if gums

unavailable. Gums

should be moist.

(Plus, Carrying out

a clinical

Pale/White, blue, bright

red, yellow Gums can also

be tacky, dry. (Plus,

Carrying out a clinical

examination, 2015)

Pale/white, hypoxia, shock, dehydration.

Yellow may indicate elevation of bilirubin in the blood, this condition is called

Icterus and the yellow appearance called Jaundice.

Blue mucus membranes (cyanosis) occur in animals that cannot provide their

tissues with enough oxygen, these animals develop a condition called hypoxia.

Bright red mucous membranes (congested) may show in animal that is hyper

perfused, a condition which blood flow to peripheral tissues are increased. Could

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examination, 2015) also be signs of allergic reaction.

Tacky or dry gums show the animal is dehydrated. (Colville, 2008)

Capillary Refill

Time (CRT)

2 seconds 1-2 seconds. (Plus,

Carrying out a

clinical

examination, 2015)

Over 2 seconds (Colville,

2008)

CRT over 2 seconds

Compromised cardiac output, low blood pressure or severe peripheral

vasoconstriction.

CRT under 1 second

High blood pressure and those in hyper compensatory states. (Colville, 2008)

Dental Score 2 mild. See

appendix 2

0 Healthy

periodontium (Plus,

Carrying out a

clinical

examination, 2015)

1-4 See appendix 2 1-4 See Appendix 2 (Plus, Carrying out a clinical examination, 2015)

Lymph Nodes.

Submandibular,

Prescapular,

Popliteal,

Non Palpable Submandibular,

non-palpable.

Prescapular, non-

palpable. Popliteal,

non-palpable.

Swollen, palpable Enlargement

Inflammatory, infectious or neoplastic conditions (Orpet, 2011)

Lymphadenopathies cause enlargement and may indicate infection or neoplasia which may

be localized or systemic (Cooper, 2014)

Skin No signs of

alopecia,

dandruff, matting,

scuffing,

greasiness.

No signs of

alopecia, dandruff,

matting, scuffing,

greasiness.

Alopecia, dandruff,

matting, greasiness,

discharge, wounds,

inflammation (Plus,

Carrying out a clinical

examination, 2015)

Alopecia

Endocrine disease, hypothyroidism.

Reactions from drugs, vaccines and insect stings.

Allergies to house dust, mites, pollens, soaps, detergents and chemicals (Cooper, 2014)

Forelimbs No lumps,

swelling,

inflammation. All

clean. Nails not

Free range of

movement, flexion,

extension and

rotation of

Wounds, abrasions,

swelling, discomfort, ab

normal sounds. Frayed

and torn nails. Muscle

Trauma

Road accidents

Falls.

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needing trim. No

wounds. Paws,

nails checked. No

sign of any pain

or lack of

movement

forelimbs. So signs

of discomfort,

swelling or

abnormal sounds.

Feet, pads and

claws should have

no wounds,

abrasions, foreign

bodies. No frayed

and torn bodies

(Cooper, 2014)

wastage. (Cooper, 2014) Sounds or heat through palpitation

Dislocation or fracture (Cooper, 2014)

Thorax No lumps,

wounds, unusual

sounds.

No wounds, lumps,

unusual sounds

such as crackles

and rales (Cooper,

2014)

Cackles and rales, wounds,

lumps.

Presence of pulmonary or cardiac problems.

Abnormal lung sounds such as crackles and rales

Thoracic pathology such as pneumonia, pulmonary oedema or bronchitis.

Wounds could be sign of trauma from a road injury or animal fight (Cooper, 2014)

Sebaceous cyst, lipoma,

Spine No lumps,

wounds, signs of

pain.

No lumps, wounds,

signs of pain.

Paralysis, pain, weakness,

faecal/urinary

incontinence (Cooper,

2014)

Intervertebral disc disease,

wobbler syndrome,

tumour,

fracture (Cooper, 2014)

Abdomen No lumps,

wounds, swelling

Standing freely. No

swelling (Orpet,

2011)

Tucked or hunched up.

Swelling, distension

(Orpet, 2011)

Distension, fluid could be haemorrhage, gas within stomach, pregnant uterus or full

bladder could cause abdomen to appear distended. Lumps could possibly be tumours.

(Cooper, 2014)

Hindlimbs Paws and nails

checked. Nails

not needing trim.

No wounds,

Free range of

movement, flexion,

extension and

rotation of

Pain, heat, swelling,

deformities, restricted

movement. (Orpet, 2011)

Trauma such as

Road accidents

Fractures

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lumps. Limited

range of motion

on right leg, left

not as bad.

forelimbs. No signs

of discomfort,

swelling, abnormal

sounds. Feet, pads

and claws should

have no wounds,

abrasions, foreign

bodies. No frayed

and torn nails.

(Cooper, 2014)

Torn muscles (Cooper, 2014)

Perineal Area No soiling,

discharge,

inflammation or

swelling.

No soiling,

discharge,

inflammation,

swelling. (Cooper,

2014)

Soiling, discharge,

inflammation, swelling.

(Cooper, 2014)

Soiling – diarrhoea

Discharge - disease such as masses or furunculsis. Anal glands would also be examined for

signs of infection or swelling. Inflammation or swelling can be sign of perineal ruptures.

Benign prostate hyperplasia is also possible in older unneutered canines. (Cooper, 2014)

Penis/scrotum No signs of

swelling,

discharge or

redness. Two

descended

testicles

No signs of

swelling, discharge

or redness.

Discharge, inflammation,

redness, one testicle

descended (Cooper, 2014)

Cryptorchidism, lumps could be tumours. Mucosal eversion (Cooper, 2014)

Tail No signs of injury,

pain. Normal

carriage of tail.

No wounds, no

pain, normal

carriage. (Plus,

Carrying out a

clinical

examination, 2015)

Wounds, pain, abnormal

carriage. (Plus, Carrying

out a clinical examination,

2015)

Wounds, pain and abnormal carriage could be signs of trauma such as

road accident,

tail caught in door or some other object (Cooper, 2014)

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Hydration

status

Mild hydration <

5%

<5% slight. (Plus,

Carrying out a

clinical

examination, 2015)

Mild hydration 5%-8%,

Moderate hydration 10%-

12%,

Severe 12%-15%. See

appendix 6 (Plus, Carrying

out a clinical examination,

2015)

Diarrhoea, increased urination drooling, urinary tract obstruction, heatstroke. (Munkevics,

2014)

Temperature 38.2° C 38.0°-39.0° Celsius

(Lee, 2011)

Below 38.0 degrees

Celsius.

Above 39 degrees Celsius.

Elevated temperature due to

Exertion, stress, excitement, infection, hyperthermia.

Decreased temperature due to

Hypothermia, incipient parturition (giving birth), dehydration, shock. (Plus,

Carrying out a clinical examination, 2015)

In some animals there may be variations to the norm which may impact on anaesthesia and drugs chosen. In this case there were no abnormalities in the patient other

then the age of 15 years. This is why ACP was not used. Contraindications for ACP include the young/old and very ill or brachycephalic. In this case Morphine and Atropine

were used at a pre-med. If the patient was suffering from Addisons disease then morphine would not be recommended. If the patient had any type of liver problems then

morphine would not used If the patient was suffering pancreatitis or was suffering from shock then it would be best to avoid use of propofol and use alfaxan instead.

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Diagnostic radiography

There was no oral x-rays in this case but they are commonly done to allow visualisation of the tooth structure below

the gingiva. It also creates the ability to focus on specific teeth without superimposing of the opposite jaw and offers

as assessment of the periodontal and pulpal health of the tooth as well as bony or soft tissue that may be present.

(Cooper, 2014)

Some reasons for dental radiographs

Fractured teeth

Periodontal disease

Feline resorptive (neck) lesions

Missing or extra teeth

Root canal therapy

Suspected oral tumours and fractures (Plus, Dental radiographs and nerve blocks, 2015)

Dental x-ray films come in a variety of sizes to fit a variety of mouth sizes

Size Recommended for

Size 1 (20mmx35mm) Smallest size for small or young animals

Size 2 (31mmx41mm) Taking images of single teeth or several teeth in row for a smaller dog or cat

Size 4 (57mmx76mm) Largest size and used for larger dogs

(Plus, Dental radiographs and nerve blocks, 2015)

Types of X-ray film

Type of Film Designed for

Non screen film This is designed for use without intensifying screens, this requires a very large mAs but

produces extremely fine image definition. Non screen film is only available as small dental

film. The film comes wrapped in thick, light proof paper rather than a cassette.

Screen film This is designed for use in cassettes and is used for all other studies. It has less detail

produced compared to a non screen film due to the visible light produced by the phosphor

crystals spreading out in a number of directions and will result in blackening of a large

number of silver halide grains than the initial x-ray phoyon would have done.

(Cooper, 2014)

Film Speed Description

Fast film Screen combinations require less exposure but produce poorer image definition

Slow film Produces finer details and can be called ‘high definition’

(Cooper, 2014)

Restraint

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When it comes to restraining a patient for intraoral radiographs there are a number of options available, such as

chemical, mechanical and manual.

Chemical – This is when a patient needs to be sedated or under general analgesia to be able to perform the

x-ray in the best position to get an accurate view.

Mechanical – this is when props are needed to position the patient is the correct position for best view.

Some props are troughs, foam pads, sandbags, ties and tapes.

Manual – This is handheld positioning the patient. (Plus, radiography part 3, 2015)

Positioning the patient

Sternal recumbency for maxillary incisors

Lateral or sternal recumbency for the maxillary canines, premolars and molars

Dorsal recumbency for the mandibular incisors

Lateral recumbency for the mandibular premolars and molars (Cooper, 2014)

There are three main techniques for positioning the beam head in Veterinary patients, parallel technique, Bisecting

angle technique and Extra oral near parallel technique

Parallel technique – This is the simplest of all as the film is parallel with the long axis of the object being

radiographed. This is only useful in mandibular premolars (steps for bisecting angle technique, 2015)

and molars.

Bisecting angle technique – this is the most common used in

dental radiography. This uses the theory of equilateral triangles

to create an image of the tooth in question. This technique

provides the least distortion for the image. This technique is used

to image all the incisors, canines and maxillary pre molars and

molars. Place the film as close to teeth as possible and an

imaginary bisecting angle is taken between the x-ray film and the

long axis of the tooth. The x-ray beans then intersect the

bisecting angle by 90°.

Extra oral near parallel technique – This can be used as an

alternative to bisecting angle technique for upper maxillary molars and pre molars especially in cats. The

patient should be in lateral recumbency with the target teeth nearest the table. The long axis of the target

teeth is as near parallel to the film as possible and the beam us angled at approximately 70° to the film and

target. The mouth must be opened with a prop to direct the beam onto the film, this must be done without

superimposing the top check teeth on the bottom cheek teeth. (Plus, Dental radiographs and nerve blocks,

2015)

17

In this case, if intra oral x-rays were to be taken, the patient would have been positioned sternal recumbency for the

best view of his maxillary incisors and pre molars which were extracted. The bisecting angle technique would have

been used for the best image of these teeth.

Exposure Factors

Kilovoltage (kV) – This controls the speed and wavelength of the x-rays by penetrating a high kilovoltage that

accelerates the electron beam across the x-ray tube from the cathode to the anode.

Milliamperes (mA) – This controls the heat of the filament and therefore the number of electrons produced.

These electrons make up the beam that strikes the anode producing x-ray photons

Time (seconds) – This varies and reflects the time of filament of the cathode is exposed to current to release

a certain number of electrons and to the time voltage is applied between the cathode and anode.

Focal film distance (FFD) – This is the distance between the source of x-rays and the x-ray film. It can have

effect of the intensity as when the FFD increases the intensity of the x-rays is decreased

Exposure charts – These are ideal to limit wastage of film and time in repeating radiographs aswell as

keeping the number of exposures to a minimum for health and safety. Ideally an exposure chart should be

made up for each machine with a list of kV and mA required for various areas of different sized patients. For

the chart to remain accurate all other parameters must be kept constant e.g. line voltage, quality of

processing, FFD and should include other changeables such as film screen, and use of a grid. (Plus,

Radiography part 1, 2015)

Differences between intra oral x-rays and other veterinary radiography

Intra oral Other Veterinary radiographs.

kV Fixed 40-100kV depending on size of area

mA Fixed 50-100mA depending on size of area

Exposure times Mandible – 0.2 seconds

Maxilla – 0.3 seconds

0.06 seconds. For example thorax

Fixed focal distance (FFD) 20 – 40cm 75cm for portable machines, 100cm for

fixed machines

(Plus, Radiography part 2, 2015)

Developing dental x-rays.

Intraoral dental film can be processed in a number of ways including

18

Chairside – This is a purpose made enclosure that contains three or four receptacles (developer, rinse water,

fixer, or developer, rinse water, fixer and rinse water)

Automatic processor – that’s suitable for processing dental film

Manual – this is in the practice darkroom using the manual technique. This is longer than other manual

developing at 4 minutes (Plus, Dental radiographs and nerve blocks, 2015)

Digital dental radiography

This is becoming increasing popular in the veterinary practice. This system eliminates the need for processing

chemicals and takes up less space but also lowers x-ray exposure settings and the images are visible almost instantly.

There are two types of digital radiographic systems

Direct

Indirect

The direct system uses a digital sensor that is placed in the mouth the same way as intraoral film. The teeth are

exposed and the image appears on the computer screen within seconds.

The indirect system uses phosphorescent plates (within protective envelopes) are placed in the mouth in the same

way as intraoral film and the teeth are exposed in the usual way. The exposed plate is then placed in a drum reader

which converts the phosphorescent image into a digital image that can be viewed on the computer screen. This

system takes longer but has a large range of different plate sizes. (Caiafa, 2006)

Health and safety

The dental procedure area should not share airspace with the surgical preparation area, sterile procedures room or

theatres. This is due to the aerosolized plaque and bacteria generated during the dental procedure. Some dental

chemicals contains solvents so the room should be well ventilated and ideally an air extraction system. All

instruments and equipment should be within easy reach.

Gloves, safety spectacles and mask should be worm by all involved in the dental procedure. This prevents any flying

material from entering your mouth eyes or body. This also protects against a broken high speed bur flying through

the air. (Cooper, 2014)

Proposed treatment

The proposed treatment was initially a scale and polish without having a clear look into the canines’ mouth. While

under anaesthetic it was noticed that there was some decay and it was best to remove these teeth. The teeth that

were to be removed were the upper right incisor 102 due to a fracture and pus around root. Also removed upper

right pre molar 1 and 2 (105 & 106) due to gum recession and exposed furcation on pre molar 2 (106).

19

The Vet also extracted upper left pre molar 1 and 2 (205&206) for the same reasons as the previous teeth. Both the

canines had mild gum recession but the rest of the teeth were good. The expected outcomes of performing this is to

minimise pain and discomfort for the patient.

Because the patient was 15 years, a pre anaesthetic blood screen was advised and completed and the patient was

also put on fluids to aid in the speedy recovery from surgery.

As the patient was un neutered the Veterinarian advised it would be best to feel the prostate while anaesthetised,

this is because prostate abnormalities in canines is common and due to the old age of this canine. Some

abnormalities can include benign enlargement (hyperplasia), bacterial prostatitis, prostatic cysts and prostatic

tumours. The clinical signs of these are difficulty urinating and defecating and the presence of blood in the urine or

semen. (Cooper, 2014) None of these clinical signs had been noticed by the owner.

Scaling

Used to remove tarter

Indications for extraction include

Mobile teeth

Retained deciduous teeth

Teeth destroyed by disease

Endodonticaly diseased teeth

Crowding of teeth (Caiafa, 2006)

(Austin Veterinary Center, 2015)

Dental hygiene in animals is just as important as it is in humans, they can suffer from periodontal disease. There are

two forms of periodontal disease such as Gingivitis, which is the reversible inflammation of the gingiva. Periodontitis

is the inflammation and irreversible destruction of the tooth’s supporting structures such as gingiva, periodontal

ligament, cementum and alveolar bone. (Caiafa, 2006) In the Below

picture, the difference between a healthy mouth and a not healthy

mouth are quite obvious, poor hygiene and care will lead to bone

loss, missing teeth and large pockets around the teeth.

(abrams forest vet clinic, 2014)

Equipment Preparation

20

All Instruments in dental procedures must be sharp, clean and sterilized in order to work efficiently on a patient.

This will reduce trauma to the gingival tissues by less time with the tooth. Scalers, curettes, luxators and elevators all

require regular sharpening. This is done to maintain a sharp cutting edge and to preserve the original shape of the

instrument. Heat sterilisation will result in blunting of the instruments so a clean sharpening stone should be

available during procedures.

Hand instruments should be cleaned and sterilised like any other instruments involved in veterinary procedure to

minimise any possible chance of infection.

Power equipment should also receive regular maintenance weather by clinic staff or the supplier. All the hand

pieces on the machine need to be kept lubricated, this was done in this case by unscrewing each hand piece and

putting a couple drops down each piece and screwing them back together. In this

case the ultrasonic scaler tip gets sterilised after each use and put into the hand

piece when setting up for a dental.

The level of solution needs to be checked, this ideally contains chlorhexidine to

help reduce any bacterial growth. (Aspinall, The complete Textbook of Veterinary

Nursing, 2006)

In this case all the dental instruments are all kept together in a dental kit in a pack.

This is unpacked and opened for Vets use. The scaler tip is inserted in to scaler

and some polish paste1 put onto a stick. A disposable oscillating prophy angle tip is

also put on the slow speed hand piece.

In this case our dental kit was a 12 piece extraction kit with a few extras.

Instruments Used for

6 stubby handle winged

elevators ranging in size from

1mm-6mm

This assist in extraction of the tooth. The sharp winged tip allows easy insertion

into the periodontal ligament The winged tips have been shaped to match the

size and shape of the tooth’s root structure (1-6mm) and provides leverage of

extraction of teeth.

Periosteal elevator double

ended

This is used to lift a muco-periosteal flap off the bone when performing surgical

extractions.

Extraction forceps These are used to grasp the tooth and remove from the socket once it’s

loosened.

Mayo-hegar needle holders Needle holders in case stiches are needed after removal of teeth

Iris scissors Cutting skin or suture.

Scalpel blade holder Scalpel blade is used to free the gingival attachment to the tooth. Size 11

1 Iclean Prophy paste. 1m3. Australia 21

scalpel blade is used.

subgingival curette This is used to clean plaque and calculus from the tooth root surface and below

gum.

Supragingval scaler This scaler is used to remove plaque and calculus from tooth surfaces above

the gum.

explorer/measuring probe This probe has periodontal markings printed on the handle for periodontal

probing.

tartar removing forceps These are for removal of heavy calculus from the tooth surface.

Sickle scaler Used to remove plaque and calculus from tooth surface. Can get into

developmental grooves and blood grooves.

Burs These are required for sectioning of teeth and removing of alveolar bone.

(Phillip Bloom, 2013)

Patient Surgical Preparation

Most patients undergoing a general anaesthetic will experience hypothermia, especially in dental procedures by

Heat loss is further exacerbated by water from the ultrasonic dental machine wetting the patient’s body.

Large volumes of water flood the pharyngeal area during ultrasonic scaling. The patient may aspirate water

or loosened debris

Pain from possible extractions

This can be prevented by

Heat pads

Padded surfaces – towels, bubble wrap

Keeping animal dry – replace wet towels with dry towels

A form of drainage for excess water – position head lower

than body

It is also important to ensure water is not entering waterways

prevention can be achieved by

Using a cuffed Endotracheal Tube

Oropharynx or throat pack

Patient positioning, head lower than body (Plus, Dentistry Part Two, 2015)

In this case the head pad was wrapped in bubble wrap and then in a towel. A large towel was then placed over the

dental crate. A rolled up small towel was prepared and a towel and blanket. These were put on top of the patient

22

during the procedure and the rolled towel was placed under the neck to prevent water entering the patient. A rolled

up swab with string was placed down the patient’s throat to prevent any leakage.

Staff Preparation

Personal Protective Gear Justification

Face mask Prevents bacteria and contaminants entering the

mouth or being inhaled

Glasses This prevents bacteria or contaminants entering the

eyes would could possibly cause conjunctivitis

Gloves Prevent any contamination from hands or fingernails

entering the patients mouth and possible open wounds

inside mouth.

Actual treatment

There are 12 steps involved in an ideal complete dental prophylaxis

1. Periodontal probing and charting

2. Oral radiography

3. Recording of all findings and development of treatment plan

4. Gross removal of supragingival plaque and calculus

5. Supra/subgingival debridement

6. Gingival surgery and open root debridement

7. Polishing for removal of more plaque

8. Sulcular lavage

9. Antiomicrobial treatment

10. The use of osteo-inductive agents to regain attachment loss

11. Home-care advice and instructions

12. Recall and review (Caiafa, 2006)

Ideally prior to scaling the teeth, the oral cavity should be flushed with chlorhexidine as this has been shown to

reduce aerosolized bacteria, plaque and calculus. This did not happen in this case. The teeth were then

examined for any type of fractures or abnormalities for extractions. This was recorded on a dental chart. See

appendix 3

23

Calculus was firstly removed with calculus removing forceps and then curette was used subgingivally to remove

any subgingival deposits. The scaler was then used supragingivally to scrape away any plaque. Both these

instruments should be pulled away from gingiva towards the crown of the tooth.

If the scaler was used subgingivally it could damage the gingival tissues because of the sharp tip and hence

should be pulled towards the crown to prevent any damage.

An ultra-sonic scaler was also used in this case, this has coolant water directed from the tip and this liquid is

responsible for cavitation which help dislodge the calculus. One side of the patient was done, then the animal

turned over to do the same with other side.

Important points when scaling with an ultra-sonic scaler

The point of the ultra-sonic scaler tip should never be used against the tooth, as this will engrave the

tooth surface

Ensure plenty of water coolant is used to keep the scaler and tooth cool and to flush away debris and

keep the oral cavity clearly visible (Cooper, 2014)

Do not hold on one tooth for more than 10 seconds to prevent concentration of heat or gouging the

tooth.

Activate the unit by foot pedal before the scaler comes in contact with tooth to ensure there is adequate

water flow.

Use the side of the scaling tip and constantly move over the tooth using circular brush like strokes. (Plus,

Dentistry Part Two, 2015)

A three way syringe was used then to flush the mouth. A three

way syringe consist of water, air and mist. This is a useful way to

keep the oral cavity clear by flushing out any debris and

maintain visibility.

Polish was then placed on the low speed hand piece with the

disposable prophy angle attached and teeth polished on one

side then the patient turned and other side polished. The point

of polishing is to smoothen the teeth after they were scaled

(which roughened the teeth) and to also remove any residual

plaque. (Caiafa, 2006)

24

As mentioned earlier in proposed treatment, once the canine was under anaestetic it was acknowledged that

extractions will take place, in this case this was due to gum recession and furaction but there a number of reasons

that would require Veterinary intervention such as

Fractured teeth

Discoloured teeth

Missing/extra teeth

Resorptive lesions

Inflammation and reddening

Furcation

Teeth mobility (Aspinall, The complete Textbook of Veterinary Nursing, 2006)

Nerve Blocks

Two nerve blocks were used in this case, both were infra orbital canals. These are injections of local anaesthetic in

closeness of a nerve and the transmission of pain nerve impulses are not conducted along the nerve pathway and

therefore not perceived by the patient. These also eliminate the perception of pain, making surgical anaesthetic

depths unnecessary. Therefore this benefits the patient by lowering anaesthetic dose and recovering quicker,

reduces the need for analgesia during and immediately post op and improves patients comfort level. (Plus, Dental

radiographs and nerve blocks, 2015)

Recording dental charts

Recording dental charts are an important part of an animal’s medical history. Information to record on the charts can

include the following

Calculus scores

Gingivitis scores

Periodontal probing depth

Furcation lesions

Mobility

Gingival recession

Gingival overgrowth

Presence of traumatic injuries (fracture, foreign bodies)

Exposed pulp (Cooper, 2014)

Post procedural environment management25

All instruments need to be soaked in enzyme cleaner after use, and rinsed in distelled water. These instruments are

just as important as any other instruments used in surgery and need to be keep lubricated on a regular basis. Once

instruments are dried, they are stacked in the appropriate kit and then autoclaved. The scaler tip also gets removed

and soaked in enzyme cleaner and sterilised.

The dental machine is whipped down with Trigene, all the towels washed and put away. The machine is then packed

up and put aside in a storage area. Once all the instruments are sterilised they are put back in the dental kit adjacent

to the dental sink.

Waste

Item Waste Classification (non-

hazardous, hazardous.

Biohazard, infectious,

sharps)

Short Term Disposal Long term disposal

Scalpel Hazardous – Biohazard,

sharps

In a sharps container that

must be: leak proof, non-re-

useable, puncture proof, have

a aperture that inhibits

removal of contents (Plus,

Surgical Veterinary nursing 1:

writing case studies, 2015)

Waste is taken away by approved

medical waste company for

incineration (Plus, Health and

Safety, 2015)

Extracted teeth

Bloodied swabs

Packing swabs

Hazardous, bio-hazardous In a separate bio-hazardous

labelled bin with the bio-

hazard symbol on it (Plus,

Surgical Veterinary nursing 1:

writing case studies, 2015)

Waste is taken away by approved

medical waste company for

incineration (Plus, Health and

Safety, 2015)

Face mask Non-hazardous General waste bin Waste is taken away for disposal

for landfill or incineration. (Plus,

Health and Safety, 2015)

Post op care

26

Extubation

Before extubation takes place ensure you turn the isoflurane off and flush the anaesthetic gas out of the system reduces risk of

violate gases escaping the patient into the atmosphere and also

Disconnect the circuit from the ET tube and

Untie the ET tube from the patients head.

Deflate the cuff

Extubate when patient has a gag reflex on exhalation

Follow the curve of the tube when extubating

Lay patient with neck extended and tongue pulled forward

Must take extra care in brachycephalic dogs – leave tube in until patient is lifting heard. (Plus, Post anaesthetic care -

Extubation and recovery period, 2015)

The patient was extubated on the procedure table and then carried into the warmed kennel room. The canine was placed in

sternal recumbency, this allows any fluids in the mouth to run out the mouth and not down the oesophagus.

27

Temperature

Time Taken Result Normal value Variations from normal Actions taken

12.50pm 37.9°celcius 37.5°-38.5°celcuis Hypothermia In this case the patient was a little cold but nothing of concern. An electric heat pad was already under

patient and a blanket was on top. Snuggle safes, thermos blanket, weatbags, hot hands and extra

blankets can be used if the patient is suffering hypothermia. Care must be taken to not overheat the

patient. (Plus, Monitoring Patient Recovery, 2015)

1.30pm 38.0°celcius

2.30pm 38.2°celcius

Pulse Rate

Time taken Result Normal values Variations from normal Actions taken

12.50pm 128BPM 60-180BPM Tachycardia,

bradycardia, weak,

thready pulse.

Tell Veterinarian

1.30pm 146BPM

2.30pm 162BPM

Respiration Rate

Time taken Result Normal value Variations from normal Actions taken

12.50pm 16RPM 10-30RPM Tachypnoea,

bradypnoea, dyspnoea.

Tell Veterinarian. Ensure airway is patient, supplement with oxygen by ET tube or face mask. (Plus,

Monitoring Patient Recovery, 2015)1.30pm 20RPM

2.30pm 20RPM

28

Indications of pain in canines

Unsettled, restless

Uncomfortable when resting

Hunched, praying position

Whimpers, crying, groaning, barking

Biting, chewing at wound site

Reluctant to respond when beckoned

Avoids interacting with surroundings

Droopy eyes, worried facial expression (arched eyebrows,

darting eyes)

Flinches, whimpers, cries, pulls away when surgery site touched

Aggression

Weak tail wag

Inappetance

Reduced weight bearing (Plus, Physiology of Pain, 2015)

The patient was pain scored at 3pm and the result was 1 out of 4 on the Colorado State University Canine Acute pain Scale by

the Student Vet Nurse. (See Appendix 4)

This was achieved by

Content to slightly unsettled or restless

Distracted easily by surroundings. (Hellyer PW, 2006)

As the patient is in mild pain, the Veterinarian felt the canine did not need the Temgesic for any further pain relief, patient was

given Caprieve on waking from procedure. Caprieve is an analgesic, anti-inflammatory and anti-pyretic. Patient was given

Vetamox for the next 3 ½ days. This would prevent any bacterial infection from the teeth extractions. (Ethical Agents NZ, 2015)

Possible Complications

Some possible complications of dental extractions in canines are

Incomplete extraction – This is when teeth fragments are not all extracted from the mouth causing draining

tracts, nasal discharge, unrecognized pain and damage to adjacent teeth.

Root fracture – This can commonly happen due to technique of extraction. Roots can be curved, hooked, or

bulbous near the apex. These variations can make it impossible to “pry” the root out of solid alveolar bone.

Haemorrhage – This can happen when a major artery is damaged in the mouth. but is most common when

working near the inferior alveolar (mandibular) artery located in the mandibular canal or the infraorbital

artery located in the infraorbital canal (above the upper fourth premolar and molars) in both dogs and cats.

(Woodward, 2013)

Some signs that would indicate complications could be

29

Swelling

Redness

Bleeding

High pain score (Cooper, 2014)

Just like any other surgery it is important to ensure the patient is comfy and being well looked after. This was

achieved by regulary checking in on patient and siting with the patient for some time. The patient was offered a

small heated soft meal and water and taken outside for toileting.

Nutrition

After the patient had woken sufficiently after the procedure, the canine was given some mashed up tinned dog food.

This was also heated to appear more appealing.

The patient will need at least 3 days eating soft food, it would be recommended to feed a diet such as Hill's Science

Diet, Mature Adult Savoury Stew with Beef & Vegetables. This diet is specifically designed for mature canines over

the age of 7 years.

Upon completion of the soft food it is recommended to commence a specific dental diet such as Hills t/d. The canine

should be weaned gradually onto the new diet by mixing increasing amounts of the new food with the old food over

7 days.

(Hills pet nutrition, 2015)

Hill's Prescription Diet t/d Canine is formulated with the following benefits:

Unique kibble scrubs away laden plaque in the mouth to promote systemic health

Clinically proven to reduce plaque, stain and tartar build-up

Reduces bad breath

Added antioxidants to control cell oxidation and promote a healthy immune system

30

Awarded the Veterinary Oral Health Council (VOHC) Seal of Acceptance for helping reduce both plaque and

tartar accumulation. (Hills pet nutrition, 2015)

Fresh drinking water must be available to the animal at all times

Discharge

Discharge Instructions See appendix 5

Instruction Justification

Water and small meal can be offered tonight. Anaesthetic could still be In system and could cause nausea. Because

animal was fasted, they might eat too quickly and vomit.

Please keep Jack warm and quiet this evening Anaesthetic drugs can affect animal’s ability to thermoregulate and could

cause hypothermia. Also helps the wound heal and prevents damage to the

surgical wound

Jack has had extractions please feed canned

food or dry food softened with water for a few

days.

As extractions are painful they may find it easier to eat soft food for the

next few days.

Some dogs experience throat irritation from

endotracheal tube

During the procedure the patient was anaesthetised and in order to

maintain the health of the patient, a endotracheal tube was needed

Please read instructions for antibiotics

carefully, need to be discussed in full in

discharge.

Ensures client understands the medication that needs to be dispensed to

the patient. Half a pill twice daily with food.

Preventing tartar home care Providing options to client about how to care for the health of the animals

teeth

After hours contact number provided Legally all clinics must provide an after-hours contact

(Plus, Admit and discharge a patient, 2015)

After the procedure the Veterinarian informed the student that the patient will need daily brushing on his canines to

prevent any tartar and help the gum recession not get any worse, the veterinarian informed the student about

dental diets such as the Hills T/D, dental chews and toys that could assist in the dental care and prevent tartar

accumulating or getting any worse.

Follow up phone call was due 5 days after the procedure, as student is in regular contact with Vets North Helensville

this call was not needed.

31

Discussion

The proposed treatment was a scale and polish and any extractions if needed. The patients’ prostate was also

checked while under anaesthetic. As this was my dog, I have learnt a lot about dental hygiene and the importance of

it. Jack has had bad breath for a long time and I should have booked him in earlier and not left it to the excuse of the

fact that he’s 15 years old and to be expected at that age, which could actually be the case. From now on I will try

brush jacks teeth at least every three days and will pass my knowledge on to any clients about the importance.

Acknowledgements

I would like to thank the team at Vets North Helensville who allowed me to bring my animal in and help with this

procedure. This was Jacks first time under anaesthetic and Vet care and it was awesome to be a part of it.

32

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Dentistry case study