Ep 143- What Are the Key Guidelines for Tooth Extractions and Vital Pulp Therapy?

Ever wondered when a fractured tooth in a canine patient should stay, or when it’s time to extract? Discover the intricacies of root fractures and vital pulp therapy in this quick 13-minute episode!

 

Quick Summary: In this episode, Brett Beckman dives deep into key dental decisions faced by veterinarians, focusing on canine tooth fractures. He covers when to extract, signs of periodontal disease, and alternative treatments like root canals and vital pulp therapy. This informative episode will enhance your practice skills in veterinary dentistry.

 

Guest, Cast, and Crew Information:

1. Host: Brett Beckman, Board Certified Veterinary Dentist

2. Sponsored by: IVDI

 

Main Talking Points:

1. Root fractures in canines – extraction vs. retaining the tooth.

2. Periodontal disease and its impact on fractured teeth.

3. Understanding lucency around fractured roots.

4. When and how to use root canal or vital pulp therapy.

5. Best practices for extraction with a mucoperiosteal flap.

 

Interesting Quotes:

1. “If there’s no lucency and no periodontal disease, a root fracture below the bone might never be an issue.”

2. “Vital pulp therapy can save teeth, but timing is critical – ideally within 24-48 hours of the fracture.”

 

Timestamps:

1. [00:00] – Introduction and opening.

2. [01:30] – Monique’s question: When to keep or extract a fractured tooth.

3. [03:45] – Signs that a fractured tooth needs extraction.

4. [05:50] – Vicko’s question: Lucency and root canals.

5. [09:10] – Kimberly’s question: Explanation of vital pulp therapy.

6. [11:50] – Carol’s question: Root canal viability over time.

 

 

(Veterinary dentistry, canine tooth extraction, root fracture, periodontal disease, vital pulp therapy, root canal, veterinary dental procedures, lucency in teeth, tooth extraction in dogs)

 

Key Points Summary:

1. Not all fractured teeth require extracti

Episode Transcript

Brett (00:00):
Welcome to the Vet Dental Show.
I'm Brett Beckman, board certifiedveterinary dentist, and we bring this
podcast to you every Wednesday as aveterinarian, as a technician, as a
dentistry team to help you be even betterin veterinary dentistry and your practice.

(00:20):
We're sponsored and partneredtoday with the Veterinary
Dental Practitioner Program.
If you're interested inbeing among the best.
anywhere in general practice asa team in veterinary dentistry, I
invite you to request an invitation.

(00:43):
Let's go to ivdi.
org slash inv, like invitation, firstthree letters, so ivdi, International
Veterinary Dentistry Institute, ivdi.
org slash inv.

(01:06):
And we'll get you theinformation that you need.
So Monique has a question, with a tooththat has only a root fracture, would there
ever be a time where the tooth could stay?
And that's a great, that's a greatquestion, and yes indeed, a lot
of times, and maybe more oftenthan not, that tooth can stay.

(01:28):
If you've got a tooth that is undergoingresorption, around the fracture, but
it's under the bone and there's noperiodontal changes there, then that is
probably never going to be a problem.
That root fracture under the bonelevel with no perio care, or no perio

(01:50):
involvement it does not require extractionas long as there's no lucency there.
If there is a lucency present,then with that lucency, You want
to make sure that it is indeed alucency and not a chevron sign.

(02:15):
With a case where you have radiographicchanges, like the one you're looking at
if you're live, and the one I'll describeif you're watching this on the pod, or
listening to this on the podcast, we'vegot an enlarged periodontal ligament
space around the root segment, whichmeans it's dislodged from the bone.

(02:39):
And, or it has periodontaldisease associated with it,
destroying the bone adjacent to it.
In either case, that tooth crown isprobably mobile, and so that would
be another indication along withwhat it looks like radiographically
and what it probes as when you probeit in order to make a determination

(03:05):
that needs to be extracted.
Radiographically, if you can see thatthere's Marginal bone to fracture
communication, so where the toothroot and the bone are supposed to be,
and where the fracture is, there'sopen space in the radiograph, and
or you have mobility of that crown.

(03:29):
Those are indications where notonly the crown needs to be taken
off, but that tooth root needs to beextracted, whether it has a lucency
or not, because it's probably going toestablish a lucency given enough time
if there's periodontal involvement.
If there's a lucency in addition to that,then that means the tooth is already
dead and the bacteria have gotten out,destroyed the bone around the root tip.

(03:53):
And so that's certainly a definiteindication for extraction of that segment.
So I hope that answers your question.
And we'll go to the next question.
And thanks for that, Monique.
And Vicky Panos, I'm not completelyclear on the indications for

(04:16):
extraction based on the x rays.
Is it the pulp cavity thatseems compromised apically?
And Vicko, we we're also doing this as apodcast, so let me describe what you're
talking to and show the people in theworkshop exactly what we're talking about.
as far as the x ray goes.
This is what Viko's talking about.

(04:37):
We've got a fourth premolar.
The distal root has maybe a twomillimeter decrease in bone density
around the apex of that distal root.
And the arrow's pointing to that,so if you're listening, you can
appreciate what that lucency looks like.
And if that lucency is there, backto the question, is there ever a

(05:01):
time where that tooth can stay?
I'm sorry, Vico, if the pulpcavity is compromised apically,
is extraction indicated?
And the answer to that is maybeand usually is, but the other
alternative is root canal.

(05:24):
So you never know.
It may be that the client wants topursue saving that tooth, and if
that lucency is just not horrendous.
And it's not associatedwith a suborbital fistula.
Then, with treatment, removing the diseasepulp, sterilizing the canal, which is

(05:47):
essentially the first phases of a rootcanal therapy or root canal treatment,
and then placing a sterile material in thecanal and then sealing that, eliminates
the thorn in the abscess, right?
When you think about thorns.
in abscesses or foreignbodies in abscesses.

(06:08):
If you remove the thorn, the abscess isexposed and drains and then it resolves.
With or without antibiotics in most cases.
Same thing here.
You remove the source of the infectionand the tooth stays where it's sterile.

(06:29):
The sterile material is not compromised.
The tooth or the bonearound the tooth root.
It starts to resolve or remains thesame and never progresses and there's no
dissolution of the apex of the root overtime, which we follow radiographically,
then that's a perfectly good alternative.

(06:51):
If the client does not want to do that,if you have a periapical lucency, there
is no instance where you would leave that.
You always want to extract a tooth.
If the owner does not opt for root canal.
If there is a periapicallucency around the tooth root.
Nice question there.

(07:12):
Let's transition to our next questionhere before we close this case.
And this is a good question thateverybody needs to know the answer to.
Because we do this a lot.
Kimberly asked about diamondfootball, or diamond burrs.
And if we only have one, what do we need?
And the diamond football burr would bethe one to go that's mainly the larger

(07:36):
one that's a canine football burr.
Kimberly asks, can you pleaseexplain vital pulp therapy?
And we use vital pulp therapy mainlyin cases where there have been super
recent fractures that the owner knowsthat the fracture was at a certain point

(07:58):
in time which almost never is accurate.
For Unless they actually see thefracture as it occurs, look at the
pulp cavity and see it's bleeding.
That's the only time that we wouldconsider historically doing something
for saving that tooth without havingto go to a root canal extraction.

(08:21):
And I think that's a laterquestion that we have.
But vital pulp therapy,essentially what it does.
It allows us to either reduce the crownwhen we've got a malocclusion, for
instance, a mandibular canine tooth that'simpinging upon the palate and digging
into the palate, causing a malocclusion.

(08:43):
Or we have a fresh fracturethat's less than 24 hours old
ideally, and uncontaminated,or at the most 48 hours old.
After that, the statistical Successrate are very poor, so we would
essentially do root canals on thoseif the owner wants to save them.

(09:05):
Or if, in practice, if theydon't that's an extraction.
You want to extract that toothif you're comfortable extracting
teeth that have no perio.
And that's with a surgicalflap, mucoperiosteal flap.
And exposure and extraction withusing burrs to remove vestibular bone,
making grooves, extracting the tooth.

(09:28):
Contouring the bone with a diamondfootball bur and then suturing that
close after radiograph confirms thattooth has indeed been fully extracted.
Back to vital pulp therapy, if that's theindication, based on what I just said,
where we're trying to save a tooth and notcompromise the pulp, then what we would

(09:51):
do would be to get down to healthy pulp.
In the case of a fracture or we woulddo a crown amputation in the case of a
malocclusion with a sterile burr under,under reasonably sterile circumstances.
And we'd remove a couple millimetersof the pulp depending on how big
that patient is maybe less than that.

(10:14):
And then that's gonna bleed, sowe have to control the hemorrhage.
And then we place mineral trioxideaggregate, which is a biological.
Cement, literally a cement that youcould go into Home Depot and buy a

(10:34):
big sack of that is the same thing.
It's just sterile and they've put itthrough the sterilizing process, but
it's essentially a cement or theyhave liquefied it to make it easily
applicable and that's what we use.
And then that sits on thepulp and lets that pulp heal.

(10:56):
And then that is cured if it's a, if it'sa liquid like we use, or if it's just the
actual cement itself, or the MTA itself.
It's placed on the pulp, and then on topof that, we use what's called a glass
ionomer, generally, or a composite,or both, that seals the restoration,

(11:18):
seals the tooth in multiple layers.
So that allows that tooth to stay viable.
And then we recheck that radiographicallyevery six months or so for a couple times.
And if it, if in a year it's still thetooth is growing, the dentin's getting
smaller with the growth of that tooth, andeverything's fine radiographically, then
we're we've got a successful procedure.

(11:40):
Success rate on those, if they're donewith a vital pulp with a malocclusion
under pretty sterile circumstances,are greater than 90 percent.
And if it's within 24 hours,probably close to 90%.
That, hope that answers yourquestion, and good question.
Good way to, to start offthis this group of questions.

(12:02):
Carol Kaluka, Is there a timelimit where a root canal would
not be an option, for instance, afracture that is a year or older?
Great question, Carol.
And, the answer to that, if there is afracture that is 5 years old, And the
changes are not super significant onx ray where you've got a huge periop,

(12:25):
apical lucency, but there's pulp exposure.
Those can still besaved with a root canal.
If the owner doesn't want to opt for rootcanal and referral, which is usually the
case, you guys are going to find out,if you're offering referral for a lot of
these things we're talking about today,that most clients are not going to do it.

(12:47):
Maybe there's not a referral practiceclose, maybe they don't have the funds
to do that, maybe saving that toothis not the best in their interest
justifiably, maybe it's not a tooththat we'd save, we save canine teeth,
maxillary fourth premolars, andmandibular first molars occasionally.
But for the most part, that's theones that we do root canals on.

(13:09):
Incisors, sometimes, if it's aworking dog, maybe a a dog that's
a special needs dog, or maybeit's a police dog, sheriff's dogs.
We do NASA down here in Orlando.
We do their bomb sniffing dogson Cape Canaveral in Cocoa Beach.
But that aside, there are times whenThat that wouldn't even play a role.

(13:33):
If you're talking about a premolaror the last molar, those are
not really functional teeth.
So we wouldn't even considerroot canals on those.
Those are always extractions.
We're not gonna do a root canalon a premolar tooth that's
not a fourth upper premolar.
It just doesn't make sense.
Those teeth are not functional.
Functional, they don't occlude, they don'tchew teeth, or chew, chew food, they might

(13:56):
chew teeth if there's a malocclusion,but they don't chew food that's done in
the back part of the mouth for the mostpart, so we wouldn't consider those.
Carol, hope, hope that answers yourquestion very good question there.
I hope you enjoyed that episode.
If you'd like more informationabout the Veterinary Dental
Practitioners Program, please submitto request an invitation at ivdi.

(14:25):
org slash inv.