Dental dilemmas in companion animal practice

I spent an hour on a recent rainy Sunday trying to escape from an Escape Room with 3 friends. Escape Rooms are team adventure games in which you attempt to solve a series of puzzles using clues, hints and hidden messages in order to achieve your ultimate objective and therefore ‘escape’ from the room.

Our scenario was to 'Escape from the Mad Scientist’ who was plotting to detonate a bomb that could destroy the whole world (far too politically contemporaneous). I went with 2 other vets (a general practitioner and feline medic), and an art therapist. We entered the room with some trepidation and excitement, and as the door closed and the countdown started (we had 60 minutes to escape) we all set about exploring the room looking for clues. At first, things seemed insignificant- pictures and film posters on the wall for instance, while others clearly meant something, we just didn’t know what yet!

Natural roles

We naturally fell into different roles - someone looking everywhere for clues that might be connected, others ferreting away in one spot trying to fathom that particular puzzle. The vets seemed to very quickly concentrate on finding the details, sifting out the irrelevant, obviously being driven by the time factor (we are used to 10-15 minute consults after all). The art therapist on the other hand had a more calm over-view of the whole room (she later described us as ‘terriers’).

By solving a clue you obtain a numerical code, which unlocks a padlock on a box or cupboard, thus releasing further clues. The first clue was solved by the feline medic- one of the pictures on the wall could be slid sideways revealing instructions to look at other pictures on the wall. Once we solved this clue, we then solved several in quick succession. We each pieced together a different part of the puzzle, but the feline medic excelled in the end. She found the first vital clue, and by having the most lateral thought process of all of us, enabled us to crack the final code. We escaped the room elated, with 6 minutes to spare.

Problem solving profession

“What has this got to do with dentistry?” I hear you thinking. Well, as a profession we have to be good at problem solving. We learn to be methodical, structured and logical at university. Clinical practice builds upon these skills, sometimes enabling us to problem-solve quicker using pattern-recognition and even implementing the (potentially controversial) ' gut-instinct’.

The addition of evidence-based veterinary medicine further enhances this process. I have great respect for the internal medics and general practitioners who can piece together huge volumes of historical, physical and biomedical data, sifting the relevant from incidental to arrive at a diagnosis. Veterinary dentistry is over-whelmingly visual, you just have to know where and how to look.

The puzzle-solving skills in dentistry start with the signalment and history, which involves knowing what information may be useful, directing us towards certain, more-likely diagnoses. The avid tennis-ball chewer is likely to have abrasive wear to many teeth, which can result in significant pulp exposure, warranting further investigation and treatment.

The young male cat with a history of being hit by a car with a fractured jaw has a 70% chance of also having at least two fractured teeth, which are painful and require treatment. The cat with a good appetite that ‘gulps’ its food and then regurgitates may also be giving you a vital clue that they have oral or dental pain, and are simply trying to get their food into their body as painlessly as possible.

Gathering the clues

The conscious oral examination adds to this clue gathering exercise. Is there asymmetrical calculus suggesting a left or right-sided source of pain? Is the gingiva alone inflamed, or are other mucosal tissues affected? The 1 year old cat that is happy and eating well, maintaining its body weight, but has marked gingivitis is unlikely to have chronic gingivostomatitis. This disease is usually seen in older cats and causes marked pain, difficulty eating and chewing and weight loss. Instead, a diagnosis of juvenile gingivitis is more likely. Swabbing for calicivirus in this instance is inappropriate.

Piecing the puzzle together

The next chance for clue gathering comes by examining the animal under general anaesthesia. This requires the clinician to examine every tooth in the mouth using a periodontal probe and if necessary, the explorer probe, and then document all findings onto a dental chart. Dental radiography is the final, and perhaps most vital part in piecing the puzzle together.

Like sliding the picture across the wall in the Escape Room, it reveals vital information, which would otherwise have remained hidden from us. Finally the code is cracked, a diagnosis reached, and a suitable treatment can then be provided.

Come and join us in December for case-based discussions on the dental dilemmas in companion animal practice. How do I treat this tooth with resorption in the cat? What is the best homecare protocol for this dog? How do I know if this tooth is painful? What’s the best therapy for gingivostomatitis? How do I interpret this dental radiograph? It could even be as much fun as going to an Escape Room.