Damaged Tooth - Nerve Exposed?

[Mim]

While cleaning the dogs' teeth today I noticed that Muddy has damaged one of his rear teeth. Off to the vet tomorrow to see if it needs to be removed or capped.

Has anyone had experience with something like this? What was the result? And roughly how much does capping or removal cost?

Now that I think about it, he has been eating his dinner slower recently.

Sorry for the poor quality of the photo

[Inevitablue]

My previous dog had a pulp cap put on a broken canine by a dental specialist. About 10 years ago that cost $500. It fell off 2 weeks later.....

The nerve then just dried out and died. After a few weeks he was perfectly fine, I just gave him pain killers until the nerve died.

[Mim]

I was wondering how good the caps would actually be. He really doesn't seem fussed by it at all but I am worried about infection. Did you have any other issues with the tooth?

[Jumabaar]

I paid about $600 for a specialist to remove a baby canine from my pup- that was consult, anaesthesia, fluids, pre and post op X-rays and post op medication at a referral centre. My regular vet had told me to leave it and when pressured said it was because he didnt have the skills to do it on a pup even though all broken teeth need something done with them to prevent infection! (rant over). So I would have paid top dollar. That being said I wouldn't want an extraction done without Xrays so if my dogs need it done in the future will probably end up back in the referral centre anyway :laugh:

Best of luck with Muddy- those are some clean teeth!!!!

ETA- all open pulp cavities, even after the nerve has died, will have infection at the root of the tooth eventually. Because the body cant close the hole in the tooth- thus the need to either remove the tooth or fill the hole artificially. Bone infection is painful but the only time people 'see' the infection is when it has eaten right through the bone and created a draining tract!

ETA again- http://www.sydneypetdentistry.com.au/faq-vet/what-to-do-if-you-see-a-broken-pet-tooth/

Edited November 6, 2012 by Jumabaar

[Inevitablue]

None, and this was a cattle dog that picked up dirty tennis balls etc. I had the pulp cap put on within 36hrs of it breaking to try and save the nerve, and he did have a course of antibiotics.

The tooth ended up as a snapped canine, no pain and the nerve just shriveled up and died.

EDIT: lol, I should add that he then snapped his lower jaw and had 2 front teeth, the broken canine and 3 molars and the broken jaw removed, but that was about 18 months later. Someone threw his ball up a flight of landscaped stairs and he tripped and went face first into the edge of the stair...

Edited November 6, 2012 by Inevitablue

[Mim]

Thank you for your reply, jumabaar, very insightful. I think I would opt for removal rather than capping as he is a very sensitive dog and if the cap did come off, I wouldn't want to put him through it again. He bounced back really well from his desexing op a couple of years ago so I am sure he will be fine with surgery if he needs it.

He is 3.5 years old and I am very proud of his teeth. My 4.5year old and 7 year old get complimented on their teeth too :D One proud owner here. I put it down to a good raw diet.

Inevitablu, sounds like one tough dog!

[BlackJaq]

ETA- all open pulp cavities, even after the nerve has died, will have infection at the root of the tooth eventually. Because the body cant close the hole in the tooth- thus the need to either remove the tooth or fill the hole artificially. Bone infection is painful but the only time people 'see' the infection is when it has eaten right through the bone and created a draining tract!

I have to say that a nerve has died in one of my own teeth due to trauma (a front tooth to boot) and I agree with Jumbaar. I did nothing with my tooth because I didn't notice to begin with. The nerve died and I got a HUGE abscess in the jaw above the tooth/nerv. I didn't notice until it erupted through my gum and that was painful and I am still battling with it after having a root canal and regular cleaning done. I am going to see a specialist about it soon. My abscess hole is the size of a pea. In my jaw. Seriously. It hurts and continuously re-infects despite root canal and plugs. Hence the specialist.

A dead nerve in a tooth does require action to be taken.

ETA: I should add that my nerve died over two years before I took any action. Hence some people who have done nothing may not have noticed any issues yet

Edited November 6, 2012 by BlackJaq

[Alyosha]

One of mine broke a tooth (1st incisor - next to the canine) off near the gumline a few months back. The vets advice was to leave it. It has healed over, he has never demonstrated pain, it has never caused a problem. The remaining tooth root holds the place in his mouth and stops the other teeth from moving.

Yes I was given the option of capping, but at a high cost and no medical, just cosmetic value. High cost and a GA just for how I want it to look = no way. I would rather do what is right by him and not put him through unnecessary surgery.

Dogs' mouths are not human mouths. A broken tooth in a dog is a different kettle of fish to a broken human tooth.

We will continue to keep an eye on the tooth, but our vet is very happy with it and doesn't predict it will cause problems, especially now that it has healed over.

I would watch it for signs of infection, and vet immediately if that is the case. Otherwise leave it alone.

[Teebs]

Kaos has cracked two teeth. One was removed because the nerve was exposed, the other the vet was happy to leave.

That was about 4 years ago and the removal and the other cracked tooth don't worry her at all, you wouldn't even know.

If it starts to bug her I will get it removed

[Jumabaar]

Fundamentals of Endodontics Brook A. Niemiec, DVM

Oral pain in patients with pulp-exposed teeth was substantiated in a recent veterinary study demonstrating that pain on chewing was significantly increased in domesticated dogs with pulp exposure versus those without [4]. Unfortunately, our animal patients almost never demonstrate overt signs of oral pain because they are quite stoic, they cannot verbalize symptoms, or the condition occurs as a consequence of natural selection [9]. In the wild, animals that seem to be weak or painful may be culled from the pack, perhaps resulting in death. A fear of culling by a client who is perceived as alpha may prevent our pets from exhibiting any or, if any, only subtle (hence, often missed) signs of oral pain [9]. When the nerve dies, much of the pain goes away; however, it is replaced by infection, resulting in a chronic disease state that affects the patient daily [10,11]. This apparent lack of pain allows clients and veterinarians to dismiss a fractured tooth, because ‘‘it doesn’t seem to bother him.’’

With irreversible pulpitis, the tooth eventually becomes nonvital because of pulpal necrosis [12]. With chronicity, the lack of immune competence of the pulp tissues to resist bacterial colonization results in bacterial contamination by the oral environment (most common) or via the systemic circulation [13]. Infection via the systemic circulation is called anachoresis and is defined as the preferential collection or deposit of particles, such as bacteria or metals, that have localized out of the bloodstream in areas of inflammation [14]. At this point, the affected tooth’s endodontic system becomes purulent (Fig. 3). The bacteria are now fortressed against host immune defenses and antimicrobials, and the affected tooth’s endodontic system is also a ‘‘superhighway’’ for oral bacteria. This bacterial superhigh- way has its on-ramp at the fracture site and its off-ramp at the apical deltas of canine and feline root apices. The bacteria and their byproducts occasionally stream through these openings into the alveolar bone and its blood supply.

Oral Pathology

Brook A. Niemiec, DVM

Crown fracture in veterinary medicine can be basically classified as complicated or uncomplicated. Complicated crown fractures have direct pulp exposure, whereas uncomplicated crown fractures have direct dentinal but not pulp exposure. Both types of fracture require therapy; however, treatments are often different. The crown of the tooth is made up of 3 layers (Fig. 3). The innermost layer is the pulp chamber (an extension of the root canal), which is filled with blood vessels and nerves that originate from the maxillary or mandibular artery and nerve. The outermost layer is the enamel, which is 96% inorganic material.6 Enamel has no sensory ability as well as no ability to regenerate if damaged or lost. The middle layer, between the pulp chamber and the enamel, is called dentin. Dentin makes up the majority of tooth structure in mature patients. Dentin is a living structure with sensory ability and the abilityto respond to stresses.6 The sensory ability is attributed to dentinal tubules, which run at right angles to the root canal system, ending at the dentinal-enamel junction. There are 45,000 tubules per square millimeter in coronal dentin.7 This means that a defect 1 cm in diameter results in the exposure of 1,000,000 odontoblasts.

Uncomplicated crown fractures are a very common finding on oral examination, particularly in large breed dogs (Fig. 4). These fractures result in direct dentinal exposure, and ex- posed dentinal tubules create significant pain (or sensitivity) for the patient. The currently accepted means by which this sensitivity is created is via the theory of fluid dynamics.8,9 In addition, some of these teeth become nonvital because of the traumatic incident, pulpal inflammation, or direct pulpal in- vasion via the dentinal tubules.10 Therefore, it is recom- mended that these teeth be radiographed to ensure vitality. If the teeth are nonvital (evidenced by periapical rarefaction (Fig. 5) or a widened root canal (Fig. 6), endodontic or ex- odontic therapy is required.11,12 If the teeth appear vital, theapplication of a bonded sealant is recommended to decrease sensitivity (please see the article on bonding later in the issue for further information).

All teeth with direct pulp exposure (complicated crown fractures) (Fig. 7) should be treated with endodontic or exodontic therapy; ignoring them is not an option.13 Before tooth necrosis, the viable nerve is excruciatingly painful.13 After tooth death, the root canal system acts as a bacterial superhighway, creating not only local infection but also a bacteremia. Bacteremias have been linked to more serious systemic diseases (see the article on periodontal disease for further information).13 Owners of these patients are often reluctant to pursue therapy because they believe “it does not seem to bother the dog.” However, fractured and/or infected teeth do affect animals, creating pain, infection, fatigue, and so forth, but often these signs are subtle or hidden. In fact, most owners see a noticeable or even dramatic improvement in their pet’s attitude and energy level after therapy is pro- vided. Owners should be educated that animal patients are typically much more stoic than their human counterparts when dealing with pain, and therefore the lack of outward signs of oral pain should not be misinterpreted as a benign state.13 Consequently, it is the veterinary practitioner’s re- sponsibility to be a patient advocate and recommend appropriate therapy.

Edited November 6, 2012 by Jumabaar

[Inevitablue]

Once the pulp cap fell off, the dental specialist told me to not worry about it and just let the nerve die.

So on his advice I did just that. Removing the whole canine wasn't an option I wanted to take.

[Jumabaar]

Once the pulp cap fell off, the dental specialist told me to not worry about it and just let the nerve die.

So on his advice I did just that. Removing the whole canine wasn't an option I wanted to take.

I am guessing veterinary dentistry has come a long way in 10yrs. I think human dentistry has too - thank god!!

[Mim]

We've been to the vet and Muddy has some painkiller + anti inflammatory tablets and some antibiotics. Because not a lot is exposed the vet isn't rushing to remove the tooth as it's a big one with three roots. He's to eat soft food for 2 weeks and then back to his normal diet and if we see any swelling or signs of infection, then he will have it removed.

[Rappie]

If the pulp is exposed, the question is not if infection occurs, it is when. A fracture like that might take more than 18 months to turn into a full blown abscess (usually appearing as a swelling under the eye) but there are likely to be radiographic changes of infection and bony changes well before then.

[Jumabaar]

We've been to the vet and Muddy has some painkiller + anti inflammatory tablets and some antibiotics. Because not a lot is exposed the vet isn't rushing to remove the tooth as it's a big one with three roots. He's to eat soft food for 2 weeks and then back to his normal diet and if we see any swelling or signs of infection, then he will have it removed.

Perhaps you could get your veterinarian to ring up a dental specialist, particularly if they are not feeling confident about treatment. As I explained earlier that is a similar story to what I was told about my pup when I went to see the local vet- i had him ring up and talk to Christine http://www.sydneypetdentistry.com.au (her number is at the top of the page), but I know the guys at this practice are also wiling to give advice- http://www.animaldental.com.au/endodontics.html (I linked to a page with some diagrams that show what will happen).

I know Christine is happy to talk to pet owners as well on the phone so that their dogs can have pain free mouths.

[Mim]

Rappie, he did say it could never get infected, or it could get infected in a week or a month or a year. The way I understood it was there is a chance the nerve with be "active" and get infected, or it will dry and shrivel up and not get infected. If you had a patient with this damage would you advise removal?

I think I might speak to another vet.

[Mim]

We've been to the vet and Muddy has some painkiller + anti inflammatory tablets and some antibiotics. Because not a lot is exposed the vet isn't rushing to remove the tooth as it's a big one with three roots. He's to eat soft food for 2 weeks and then back to his normal diet and if we see any swelling or signs of infection, then he will have it removed.

Perhaps you could get your veterinarian to ring up a dental specialist, particularly if they are not feeling confident about treatment. As I explained earlier that is a similar story to what I was told about my pup when I went to see the local vet- i had him ring up and talk to Christine http://www.sydneypetdentistry.com.au (her number is at the top of the page), but I know the guys at this practice are also wiling to give advice- http://www.animaldental.com.au/endodontics.html (I linked to a page with some diagrams that show what will happen).

I know Christine is happy to talk to pet owners as well on the phone so that their dogs can have pain free mouths.

Thank you very much, Jumabaar. Going to look into it :)

[Rappie]

Rappie, he did say it could never get infected, or it could get infected in a week or a month or a year. The way I understood it was there is a chance the nerve with be "active" and get infected, or it will dry and shrivel up and not get infected. If you had a patient with this damage would you advise removal?

I think I might speak to another vet.

Having been taking dental radiographs with a much greater frequency over the last 18 months, it's still 'when'. The absence of external signs of pain and infection does not mean that there are no changes occurring within the mouth, or even that it is not painful. Even if the nerve shrivels up and dies, that will still leave an empty pulp cavity that is open to the mouth.

At this early stage, with a carnassial tooth I would recommend referral to a veterinary dentist to discuss the options.

I would certainly discuss removal if referral was not an option. Most commonly however people choose to monitor (usually due to cost), and we end up still removing the tooth down the track.

Keep in mind that dogs and cats with horrendous mouths will continue to eat, even with loose / broken / eroded teeth and pus erupting from their gums.

Edit to add: I would certainly discuss with with Christine Hawke or another veterinary dentist. Christine is lovely - I had her as a tutor at university and have since had the good fortune to have hands-on training with her as well.

Edited November 7, 2012 by Rappie

[Wobbly]

I had a tooth removed from Jarrah a few months ago. It was cracked & I asked the vet if it was likely to be bothering her, the vet said it might be, so I got it removed. Toothaches are horrible, I wasn't going to take the chance she might be suffering, even if she shows no sign of pain. It was hideously expensive, not sure exactly, OH paid that one.

I don't know what Jarrah's former owners let her chew, rocks or something, sandpaper maybe? Her teeth were terrible when i got her (at only age 1ish), so worn down, she hasn't got much in the way of teeth really. It's something I get worried about, good to know there are pet dental specialists in Sydney. I will be calling them in the not too distant future.

IMO, better to have it removed than risk the dog being in agony and unable or unwilling to communicate his discomfort to you.

[BlackJaq]

I agree, and once the abscess is there, it might not be so easy to get rid of. As I know now first hand :p

Edited November 8, 2012 by BlackJaq