Complications of non-anesthesia dentistry: A case report

Most pet owners I have the privilege of helping truly want what is best for their pets. Professional dentistry, or COHAT is a part of the regular, necessary preventive health care appropriate for every pet. Anesthesia is required to perform this service safely, humanely and medically correctly.

While anesthesia will never be completely without risk, it is very safe. Technology for anesthesia has advanced considerably in the past 15 years. We carefully evaluate every patient prior to anesthesia, and we use the same anesthesia medications used for human infants during surgery. We regularly anesthetize patients up to 19 years of age without complications. For more information about how we keep anesthesia as safe as possible, visit our anesthesia information page.

Even though anesthesia is now considered very safe, some pet owners still worry about the potential risks associated with general anesthesia and seek other options for dental care.  Dental scaling without anesthesia is a practice that is gaining popularity. However, this is not a case of benign “teeth cleaning.” Mercer Island Veterinary Clinic and the American Veterinary Dental College do not endorse or recommend dental treatment without anesthesia. This procedure violates an important part of our oath as health care providers — to do no harm.

Dental services without anesthesia does not mean without risk.

The risks:

(Adapted from the position statement of the AVDC with the added benefit of practical experience)

1. Pain for the pet or the provider.

To be done properly, removing tartar and calculus from teeth requires a combination of ultrasonic and extremely sharp instruments. Ultrasonic scalers require water to cool them and certain parts of the ultrasonic tip can damage tooth surfaces and burn the gums, lips and tongue. The hand instruments must be very sharp in order to be effective. If a pet moves even slightly during the procedure, injury to the pet or the provider is a real risk.

Additionally, cleaning the teeth should include the area under the gums surrounding every tooth. This procedure requires delicate control of instruments and may cause bleeding and pain for even very cooperative pets.

 

2. Aspiration or Infection.

During anesthesia, a tube is placed in the airway to deliver the gas the patient breathes to remain asleep. This tube also protects the airway, keeping foreign material and liquid out of the trachea and lungs. Since ultrasounic scalers are cooled with water, a fine mist containing oral bacteria fills the air around this instrument and this can easily be inhaled by awake pets. In addition, chunks of tartar can easily be chipped off and then inhaled into the lungs during cleaning. Further, the liquid used to cool the scaler can be inhaled, resulting in choking or in worse cases, pneumonia.

Additionally, instruments should be chemically sanitized or autoclaved between patients to prevent the spread of infection.

 

3. Incomplete Examination.

Professional dentistry includes a careful examination of every surface of every tooth by the veterinarian. Teeth are evaluated for fractures, other damage, mobility (loose teeth), proper occlusion (a functional comfortable bite), periodontal pockets and disease, crowding, rotation, missing teeth (including dentigerous cysts), root exposure and many more items.

The remainder of the oral cavity is also carefully examined including the lips, cheeks, gums, tongue, under the tongue, throat and roof of the mouth. The knowledge and expertise of a trained veterinarian is required to complete a proper oral examination.

Without anesthesia, it is impossible to complete this thorough, necessary examination. Often fractured teeth or resorptive lesions occur on the tongue side which is hidden in the awake patient.  Lesions under the tongue or in other hidden areas of the mouth can’t be seen in the awake patient and it is impossible to perform proper periodontal probing and mobility assessment in the awake patient.

Failure to identify hidden fractures, resorption, tumors, erosive lesions, malocclusion and mobile teeth means failing to treat potentially painful conditions in pets.

 

4. No Radiographs.

One of the most important parts of a COHAT is the radiographs, or x-rays. Radiographs must be done under anesthesia. Think about how you have your bitewings taken when you are at the dentist. Now imagine a dog or cat having to sit perfectly still while holding the digital x-ray plate between their teeth… You get the idea.

Without radiographs, 60% or more of dental disease will be missed and left untreated because 60-75% of every tooth is comprised of the non-visible portions under the gumline and in the jaw. Tooth root abscesses, fractures, resorptive lesions, non-vital teeth, unrupted teeth resulting in dentigerous cysts and bone loss due to periodontal disease are all conditions that can be quite painful for pets and are diagnosed using x-rays. Failing to take x-rays means failing to detect and treat painful conditions, relieving suffering in pets.

 

5. Incomplete cleaning, no polishing.

Partial cleaning of the teeth does not help the pet. As we previously discussed, cleaning must be done above and below the gumline to be helpful. In addition, every tooth surface needs to be cleaned, not just the cheek side of the teeth. In order to properly clean below the gumline, in the spaces in between the teeth and the tongue and palate sides of the teeth, anesthesia is required.

During scaling, tiny and even microscopic grooves can be made in the tooth enamel resulting in a slightly rough surface. Much like sanding a smooth surface makes it easier to paint, scaling teeth can create a rough surface for bacteria to adhere more easily and create more tartar into the future. This effect is prevented using polishing.

After the teeth have been entirely cleaned, careful polishing to make the enamel surface smooth again will reduce future tartar accumulation. This type of polishing must extend to areas below the gumline to be effective, a service which can’t be effectively performed on awake pets.

Anxious dog during awake dental scaling

6. Stress and distress for the patient.

While we have discussed the mechanical problems leading to sub-standard care in cases of non-anesthesia dental services, we have not discussed the stress patients may experience as a result of these services.

Look at the image of the dog to the left. This dog is awake having awake dental scaling. What does the dog’s facial expression say? The pupils are dilated, lips are pulled forward, whites of the eyes are showing. It is easy to appreciate this dog is frightened.

Our mission is to take care of our patients’ total health: this includes physical and mental well-being. Causing undo stress and fear violates that mission. Pets who undergo this type of procedure may learn to associate fear and pain with any oral and facial handling, complicating care for this pet in the future.

 

A Case to Consider: Missy

We are commonly presented with new patients who have never had professional dentistry, or patients who have been seeking non-anesthesia dental services elsewhere. These pet owners are not neglectful, they are just following recommendations and trying to do what is best for the pet. We are here to educate pet owners about proper medical treatment and provide those treatments every day.

Missy's teeth had very little visible tartar

Sadly, many of these patients who have been treated with non-anesthesia dentistry have fallen victim to the risks I’ve discussed earlier in this article. Today we will discuss Missy*.

Missy came in for an annual checkup. During the checkup, we recommended professional dentistry, or COHAT, based on her age and breed. She had very little tartar on the teeth but some gingivitis was present and a front tooth was obviously broken.

 

On the day of Missy’s procedure, she was screened and found to be a good anesthesia candidate. She was anesthetized and full-mouth x-rays were taken as well as digital images during the veterinarian’s oral examination.

Periodontal disease not treatable during non-anesthesia dentistry.

Although Missy had very little visible tartar, she had extensive periodontal disease. One reason for this is her teeth are crowded together because of her breed. Crowding makes it more difficult for the gums to seal tightly to the teeth and form a protective barrier against bacteria. We already discussed that during awake dentistry it is not possible to clean below the gumline or in tight spaces between teeth. This is an example of Risk 5: Incomplete cleaning, no polishing.

Missy had advanced periodontal infection between her teeth. This condition causes discomfort and can lead to bone destruction and tooth loss. In Missy’s case, extractions were required.

Missy also had a number of broken teeth. She had been chewing on bones to help remove tartar as recommended by the pet store. However, bones are too hard for teeth. Many dogs break teeth chewing on bones, antlers, nylon or plastic bones, milk chews, rocks, ice cubes – any item that can not be flexed slightly or dented with a thumbnail is hard enough to cause tooth fractures.

One of Missy's fractured teeth

Missy's fractured premolar - one of several

These broken teeth had not been mentioned to Missy’s owners by the people performing her oral care. This is an example of Risk 3: Incomplete Examination. The person cleaning Missy’s teeth was either improperly trained to recognize the significance of dental fractures, or simply failed to notice and report them to the owner.

Bone loss due to untreated tooth fracture

Missy was also a victim of non-anesthesia dentistry Risk 4: No Radiographs.When a tooth is broken, the living interior of the tooth or “pulp chamber” can be opened, as was the case with Missy. When the protective outer layer of the tooth is broken away, bacteria can travel into the tooth, killing it. This can lead to infection and bone loss around the tooth roots as well. This was the case with Missy and her broken teeth required extraction because of the bone loss around each root and the depth of the fracture.

Missy also had another diagnosis seen on her x-rays: an embedded tooth. Sometimes in pets, as in people, teeth do not erupt properly into the mouth and remain embedded in the jaw bone. These teeth can then be treated like a foreign object by the body, which walls them off. In the process of trying to eject/wall off the tooth, the body creates what is called a dentigerous cyst. Dentigerous cysts can become large enough to lead to extractions of important surrounding teeth, or in severe cases, jaw fracture.

Embedded tooth detected on radiographs

Embedded teeth require treatment to prevent dentigerous cyst formation and its subsequent risks. Missy’s embedded tooth was found on her x-rays and extracted.

Missy’s extensive, costly dental extractions and oral surgery could have been avoided if she had been receiving proper, professional COHAT care rather than non-anesthesia dentistry. Her owners were trying to take care of her, but the people who provided non-anesthesia dental services for Missy did not educate her owners about the risks of what they were doing.

Our hope is that as more pet owners and practitioners are educated, fewer dogs like Missy will fall victim to this risky procedure.

* The names in this case report have been changed for privacy. All images and case details are presented for educational purposes with the express permission of the pet owner.