"Pulling teeth" or dental extraction?
Sometimes anologies are made with reference to "pulling teeth". People might say getting their childern to eat vegetables is like "pulling teeth". We believe the reason is that "pulling teeth" is never fun or easy.
Dr. Kressin never uses the phrase "pulling teeth" with reference to dental or oral surgical procedures. This phrase is far from an accurate description of procedures requiring skill and attention to detail. Serious complications can, and unfortunately do arise from attempts to (literally) pull teeth.
Dental extraction is an important and beneficial dental procedure when performed correctly!
Tooth extraction is a common dental procedure performed in most veterinary practices. In Wisconsin, certified veterinary technicians or veterinarians may perform dental extractions provided they have: appropriate equipment, instruments, training and have developed skill from clinical case experience. Dr. Kressin teaches dental procedures to veterinarians and dental radiology for veterinary technicians.
Some dental extractions are "awfully simple, while others can become simply awful". Some teeth are particularly difficult to extract. Well informed veterinarians prefer to refer their clients to Dr. Kressin for these more involved cases. Dental radiographs are tremendously important for the evaluation of teeth before, during, and after extraction to avoid patient injury. The "risks" associated with dental extraction are significant. Tooth fracture, failure to remove roots, excessive bleeding and jaw fracture are complications associated with dental extractions (see images below).
We have performed full mouth dental extraction on cats and dogs. Full mouth extraction means removing all of the teeth. This is an extensive procedure, however, it is tremendously beneficial for patients with specific conditions.
Cats with lymphocytic, plasmacytic, gingivitis or stomatitis are in tremendous pain. They have a life threatening condition and the optimal treatment is full mouth dental extraction. We perform between one and five full mouth dental extractions on cats per month, and clients continue to be very impressed with the value of this service! The earlier we treat these cats, their long-term prognosis seems to be substantially improved. A step-by-step procedure illustrates the extraction of the right upper fourth premolar in a cat; at this link.
Dogs with "CUPS" or chronic ulcerative paradental stomatitis also live with chronic pain. It is a tremendous shame to see these animals suffer. They have swollen and ulcerated gums, lips and tongues. Selective tooth extraction, or full mouth dental extraction has been very rewarding for these dogs.
We consider teeth as functional "assets" or non-functional "liabilities" for our patients. All teeth serve a function however, some teeth are functionally more important than others. The most important teeth are sometimes called "strategic teeth". These are the canine and carnasial teeth. The carnasial teeth are the upper fourth premolar, and the lower first molar teeth. In viewing the mouth from the side, these are the largest teeth used for shearing food items. Non-strategic teeth may be as important to the owner as the strategic teeth. We make every effort to clarify the client's treatment preferences before performing dental extraction.
Our goal is to transform nonfunctional teeth to functional teeth, if we can. Painful teeth are nonfunctional. A build up of calculus on one side of the mouth, and substantially less calculus on the other side may be an indicator of pain.
Painful teeth may have enamel defects, may be fractured (with dentin or pulp exposure), severely affected by periodontal disease, have pulpitis (inflammed pulp), pulp infection, root abscess, or be associated with a jaw fracture. The treatment options would be to repair any jaw fracture and either treat the tooth by endodontic (root canal or vital pulpotomy) therapy, or by tooth extraction. Traumatic malocclusion can be uncomfortable. With orthodontic therapy, teeth can be saved and the occlusion can be transformed for improved comfort and function. One clinical case of traumatic malocclusion (shown here) was treated by dental extraction. The owner lived too far from our facility to return for the needed re-evaluations of the occlusion. In this case, dental extraction was more logical and practical.
For some teeth extraction is the only option. There may be no reasonable way to transform a particular tooth to a functional tooth. Some owners prefer to extract teeth to avoid further complications or expense. Others want to better understand all treatment options. Some teeth require extraction because they result in malocclusion, dental crowding or teeth grinding. Supernumerary or persistent deciduous (baby) teeth typically are extracted to avoid crowding and accumulation of debris.
For some pets, the strategic extraction of deciduous (primary or baby) teeth can allow for normal jaw development. This procedure can immediately eliminate a painful traumatic occlusion and allow for a normal occlusion of the secondary (adult) dentition. This extraction procedure is often referred to as "interceptive" orthodontics.
Our initial consultation allows: full disclosure and discussion of benefits, potential procedural risks, prognosis and cost influences of each treatment option.
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This dog has persistent deciduous incisor teeth of little functional value.
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Surgical or nonsurgical extractions?
Dental extractions are classified as "simple" (non-surgical) or surgical. Dr. Hale, a friend, collegue and fellow veterinary dental consultant has stated; "dental extraction can be awfully simple or simply awful". We find with appropriate training, equipment, instruments and skill, there are far fewer "awful" extraction experiences.
Taking dental radiographs and carefully evaluating them is the mandatory first step in our practice for every dental procedure. This helps identify potential problems that may occur especially with dental extractions. Problems such as: tooth ankylosis, tooth resorption or root dilaceration (curved roots) create unique challanges, and may require special surgical technique.
Nonsurgical extraction
If teeth are severely affected by periodontal disease, the gingival attachments can be incised, and a dental elevator used to separate tooth from the alveolus (tooth socket). This is accomplished by tearing the remaining periodontal ligament using a gentle twist and hold technique with a dental elevator. The tooth then "simply" lifts out of the alveolus. The extraction site is ALWAYS sutured closed to avoid infection and to minimize patient discomfort.
Surgical extraction (step by step photos below)
Surgical extraction techniques are particularly beneficial when normal healthy teeth, supernumary teeth (many photos using this link) or abnormal teeth require extraction. Teeth with fractured roots must be removed surgically extracted, or a root tip will be left in the alveolus. Some multi-rooted teeth can be severely affected by periodontal disease of a single root. The non-surgical technique will not be appropriate for such a tooth. Surgical extraction is usually our preferred technique for most teeth.
A surgical flap is created to allow access to the alveolar bone. High speed drills are used to expose the roots. Multi-rooted teeth can easily be sectioned to allow for safe tooth root removal. Dental luxators, elevators and extraction forceps may be helpful.
If difficulties arise during dental extraction, dental radiographs help diagnose and resolve these problems. After the tooth roots have been removed, the tooth alveolus (socket) is meticulously cleaned free of debris. The mucogingival flap is carefully prepared for a tension free closure. The alveolus is ALWAYS sutured closed to avoid infection and to provide optimal patient comfort. A dental radiograph is taken to confirm that the entire tooth has been extracted, and the alveolus is free of bone, root remnants or debris.
What complications may occur from dental extraction?
Dental extraction can be fairly simple, however, they can also be very difficult. We provide step by step images on this website to help veterinarian collegues avoid complications. These are some of the potential complications associated with dental extractions that have been presented to us:
Dental radiographs, dental extractions and complications
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Pre-operative dental radiograph allows diagnosis. This tooth has endodontic "halo lesions" at the root apices (ends), periodontal disease (bone loss) and a serious root defect. Careful dental extraction technique is needed to avoid root fracture.
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Severe "perio-endo" disease is shown above, which requires dental extraction. The gingiva appeared normal, however, the periodontal probe picked up the deep defects confirmed with this dental radiograph.
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Dental radiograph demonstrates complete extraction.
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14 month old dog; fractured canine tooth extracted. Post extraction radiograph. Gentle technique avoids damage to the thin alveolar bone (tooth socket).
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11 yr cat; tooth fracture complication during dental extraction. Cat was not eating (see dental radiograph to right).
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11 year cat; extensive tooth resorption. This is a post extraction radiograph of the tooth root remnant shown above.
Meticulous technique prevents alveolar bone (tooth socket) injury and jaw fracture.
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Dog; tooth fracture complication from dental extraction. Premolar tooth with both roots fractured.
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Root fragments were removed.
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5 yr. dog; jaw fracture complication, both mandibles fractured during the extraction procedure. No dental radiographs were available to the operator.
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Closer view of the mandibular fracture. Alveolar bone (tooth socket) is shattered. Bilateral rostral mandibulectomy performed.
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Cat 6 yr.; mandibular fracture during canine tooth extraction. A wire was placed that resulted in misalignment of the jaw. The cat was unwilling to eat (see below).
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Oblique view shows fracture extended back to the fourth premolar tooth.
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Cat; mandibular fracture close up view. These jaws are extremely fragile. If we perform root canal therapy we can avoid this serious complication. Rostral mandibulectomy was performed. Cat returned to eating.
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The advantage of the dental radiograph prior to surgical extraction helps plan the procedure.
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A post dental radiograph confirms complete dental extraction and mandibular bone integrity.
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Dog; 7 months developed facial swelling abruptly.
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Dog (image to left); halo lesion observed. To the right of this tooth see abnormal dental structure unerupted.
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Periodontal probe penetrated 10 mm into the gingival sulcus.
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The above tooth was extracted as well as the adjacent premolar tooth (see below).
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This adjacent premolar was deformed.
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Premolar extracted (see left).
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Surgical extraction; lower fourth premolar! (step by step)
This is a tooth with 2 roots!
The following images were put together to illustrate important procedural techniques used in dental extraction. The images are very graphic. They are intended to help my fellow veterinarian collegues. I encourage veterinarians to purchase the best equipment and instruments to perform surgical extractions meticulously. Many complications occur from error in technique, as well as from inadequate equipment and instrumentation. Dental extraction procedures require focused attention and time to perform flawlessly. Dental radiographs are extremely important. Every veterinarian that provides teeth cleaning or oral surgery, needs dental radiography capability.
I will help any veterinarian interested in formal dental or oral surgery training. I will travel to your hospital or clinic. Efforts to avoid dental extraction complication are well worthwhile. Complications can and do occur. If you recognize complications while performing dental extraction or oral surgery, please feel free to contact me.
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This premolar was fractured and had pulp exposure (see pink nerve exposed). This is a painful condition! It is critically important to take pre-operative dental radiographs prior to tooth extraction. These radiographs allow for a diagnosis and treatment plan. It helps determine if the tooth could be or should be saved, or whether extraction is the best treatment option. This is extremely valuable in avoiding extraction complications (shown with above images).
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This dental radiograph shows the crown fracture. Notice: two "halos" around both roots. This is a severe tooth infection.
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Surgical extraction involves initial gum incisions.
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The gums are reflected back to view the underlying alveolar bone (tooth socket).
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The roots are exposed using a high speed drill.
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A special bur is used to section the tooth to allow for elevation of each root. This step helps avoid tooth fracture and leaving root tips.
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The appropriately sized dental luxator and dental elevator are chosen to gently tear the periodontal ligament which holds the roots to the alveolar bone (tooth socket).
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Instruments are used 360 degrees around the tooth root to release the periodontal ligament. A wide selection of instruments are needed for the variety of teeth (shape and sizes) we extract.
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The tooth root is lifted out of the alveolus (tooth socket) with an extraction forcepts.
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Each root tip must be carefully examined to ensure there is no root fracture.
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The remaining root is carefully removed using the exact same technique.
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This photo demonstrates removal of the final root. Notice: this tooth was sectioned.
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The roots are again carefully examined to ensure no root or crown remnants have been left within the alveolus (tooth socket).
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A pediatric high speed drill mounted with a diamond bur is used to smooth alveolar (tooth socket) edges. This provides patient comfort after the surgery.
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The alveolar bone (tooth socket) is carefully examined for bone fragments, debris and smoothness.
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The alveolvus (tooth socket) is curetted and further evaluated for unwanted debris.
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The edges of the gingival flaps are carefully prepared for closure of the surgical extraction site.
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The gingival flap is contoured and "released" to provide a tension free closure.
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We prefer to "position the flap" prior to suture closure to ensure it covers the alveoli (tooth sockets) perfectly, and to ensure it will be tension free.
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Monocryl is Dr. Kressin's preferred suture. Sutures are tied gently to avoid post operative discomfort.
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Post operative dental radiographs are taken to ensure there are no tooth remnants left.
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Surgical extraction; upper fourth premolar (step by step tooth sectioning)
This is a tooth with three roots!
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Slab fracture of right upper fourth premolar tooth.
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Periodontal probe demonstrates that this crown fracture extends into the root.
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Dental radiograph used to diagnose the problem and to determine if dental extraction or root canal therapy should be performed.
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Tooth extraction was the best treatment option for this tooth. A flap made to expose the roots, and section the tooth.
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Tooth sectioned into three separate roots. Tooth sectioning minimizes complications with dental extraction of multi-rooted teeth.
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Two roots have been removed and the palatal root is being elevated.
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Post extraction radiograph is very important to verify extraction was complete and that no root remnants remain.
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Extracted roots should be carefully examined. The root tips should be smooth.
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Surgical extraction of upper fourth premolar tooth in a "brachycephalic" breed is a little different than the case above due to dental crowding.
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This dog was referred for root canal therapy.
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Dental extraction was necessary due to the severity of the fracture into the pulp chamber.
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Dental crowding in this case required extraction of the adjacent rotated third premolar tooth.
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The alveoli (tooth sockets) were curreted free of debris prior to suturing the defect closed.
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4-0 Monocryl sutures were placed for a tension free closure of the surgical defect.
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Surgical extraction; upper first molar (step by step tooth sectioning)
This is a tooth with three roots!
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Pets are often presented for facial swelling.
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Veterinarians know not to guess at the cause of facial swellings. Dental radiographs are always taken to make the correct diagnosis. The left upper first molar tooth was the cause of this dogs' facial swelling. One cannot assume the swelling was due to the upper fourth premolar tooth.
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A mucogingival flap was created to expose the molar alveolar bone for tooth root access. The salivary duct near this tooth must be recognized and avoided.
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The tooth is sectioned to separate the roots. First section completed.
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This image demonstrates the second section to divide this tooth into three separate roots. Dental radiographs are needed.
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Dr. Kressin sutures all extraction sites closed to prevent: food entrapment, infection and pain.
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Oronasal fistula formation is a common complication with dental extraction.
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Oronasal fistula; dental extraction complication from traumatic extraction with the development of osteomeylitis (bone infection).
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These bony fragments of incisive bone were removed to allow normal healing.
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The remaining incisors were extracted. Infected and necrotic (dead) bone was removed (see above photo) and the oronasal fistula was closed using 4-0 Monocryl suture.
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Surgical extraction for treatment of a traumatic malocclusion.
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This photo was taken to demonstrate "interceptive orthodontics" performed to remove the primary (baby) teeth from the shorter lower jaw. This allowed for normal jaw length development.
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Notice the fragile root tips. It is important to ensure the entire root is removed during dental extractions.
Additional cases of surgical extraction for traumatic occlusion are shown in the dental occlusion webpage.
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Surgical extraction of right upper canine.
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Right upper canine exposed for surgical extraction.
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Dental elevator being used to gently lift this canine tooth out of the alveolus (tooth socket). Great care is taken to avoid puncture into the nose.
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Canine tooth has been removed. The alveolus (tooth socket) is curetted and gently flushed.
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The flap is sutured closed with 4-0 Monocryl suture.
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Surgical extraction for treatment of patient with severe periodontal disease.
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Cat; severe periodontal disease is a good reason for dental extraction.
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Cat; dental extraction performed. Dental radiographs are used to verify the extractions were complete .
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Dental extraction complications.
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Cat; this lower canine tooth fractured during dental extraction.
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The root tip was removed surgically with great care to avoid mandibular (jaw) fracture.
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This jaw fracture was a serious complication from the extraction of the lower canine tooth in a cat. The original operator attempted to repair the fracture. The cat was pawing at the face due to extreme discomfort.
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Blackie suffered severe chronic respiratory tract infection after dental extraction was performed.
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Oronasal fistula; extraction complication! Blackie developed a hole that allowed food and oral fluids to enter the nose.
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