The decision to extract or retain a diseased tooth is a frequent and consequential clinical decision, especially in elderly patients. In this dvm360 interview, Heidi Lobprise, DVM, DAVDC, discusses the need to assess the strategic value of teeth, stage of attachment loss, comorbidities, anesthetic risk, and client goals to help choose the best path for each patient.
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Heidi Lobprise, DVM, DAVDC: Hi, I’m Heidi Lobprise. I’m a veterinarian. I graduated from Texas A&M last century and have been practicing dentistry for over 30 years now. As a dental major, I have worked with specialist veterinary dentists, but I have also worked in industry teaching others about dentistry. I’m back in practice, but semi-retired — a few days a week. Well, of course, I really like dental stuff, but I also love senior care and senior pets, so that was a big interest for me as well.
So, in periodontal disease, do we really have to make decisions about whether to extract it or is it worth trying to save the tooth? Typically, these are teeth that have mid-range periodontal disease: stage 3, 25% to 50% attachment loss, mostly bone loss. When we look at this patient, we first look at the tooth. We’re not going to do much to save a less strategic tooth, a small incisor, compared to a canine or canine tooth. And I also look at the patient. If we have a patient with any systemic disease—heart disease, kidney problems—where the extra anesthesia time to save that tooth might be dangerous, sometimes it’s better to remove the chronically inflamed tooth to make that pet healthier with their other conditions. And sometimes it depends on the customer. Sometimes they really want to save teeth, but that usually takes more time and more money, and sometimes they choose to do the extractions anyway.
So in general practice there [are] always worries. Owners will talk about, “Oh, I’ve heard about this pet dying under anesthesia,” or “I’ve heard about the cost,” and try to think, “Well, I saw this product that can miraculously make teeth clean.” So some education is needed that this is an ongoing process with the disease. It may be below the gum line. It really takes professional care to make a difference. We can’t just brush the teeth without anesthesia, and just chewing them once a day isn’t going to cure all problems. So, it’s a continuous educational effort.
Especially when there [are] concerns about providing care under general anesthesia, we certainly love to educate [clients] about the impact dental disease can have on systemic health. We’ve been talking a lot about when you have dental disease, you have bacteria and that can get into the bloodstream and cause problems with the heart, lungs, liver, kidneys, you name it. Now, we’re thinking more about how the presence of this chronic inflammation due to dental disease is actually what’s probably driving a lot of the problems that we’re seeing, because chronic inflammation, when left untreated, can actually increase aging and affect almost every condition in the body. In fact, for chronic inflammation, there is a term called “inflammation.” It is a chronic, sterile inflammation that affects both patient morbidity and mortality and is present in every aging organ system.
I think cats have a way of inventing ways to get rid of their teeth. Stomatitis is definitely one of them. It may not be as prevalent as tooth resorption in cats, but it is certainly more serious. When we have these cats that have so much inflammation and ulceration that [it] it affects their quality of life, we usually talk about whole mouth exports and this is very important. On the other hand, tooth extractions can be uncomfortable and cause some pain. It may not be to the extent of stomatitis, but we certainly see it in a large portion of the population. In fact, some estimates suggest that up to 60% of cats will experience tooth resorption at some point. If this resorption is right down to the roots, they may not have many problems, but when it goes up to the top of the tooth, that’s when we see the potential discomfort. And then we talk about exporting to them, but usually on a select basis.
With the discussion of senior dentistry—even with the group we had in the room—besides general surgery when they’re younger, when we do surgery on an older patient, it’s usually for dental or oral reasons. The thing [about] is, yes, now we’re looking at this person who may have other diseases, comorbidities, and we’re talking about general anesthesia. That’s where we can get a lot of concern from landlords, so we really need to process those cases. Look for the problems, stabilize them, get them to where they’re stable enough so that we can administer general anesthesia, so that we can take care of that dental disease, that oral disease that’s causing inflammation, take that inflammation out – potentially help the other areas as well. If we can get rid of the inflammation, we want to do it, and we can do it in the oral cavity. So, that’s a big plus.
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