CERTIFIED ORAL PAIN FREE-MODERN TECHNIQUES IN ORAL SURGERY -Number # 51

Donald H DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
AnimalDentistrySolutions.blogspot.com
www.SilverSandsVeterinary.com
203-877-3221
1-800-838-3368
DonDeForge100@gmail.com
Number #51

CERTIFIED ORAL PAIN FREE
THE ORAL PAIN PATIENT
Diagnosis completd with:
[     ]Comprehensive Oral Radiology Evaluation (CORE)
[     ]Histopathology
[     ]MRI/C-Scan
[     ]Culture and Sensitivity
[     ]Cytology


Modern Techniques in Oral Surgery
[     ]Oral Surgery-Radiosurgery-Mucoperiosteal flap
[     ]Periodontal Surgery
[     ]Surgical Extraction
[     ]Tooth Sectioning
[     ]Guided Bone Regeneration
[     ]Osteoplasty
[     ]Alveoplasty
[     ]Periodontal Ligament Blockage
[     ]Subgingival Antibiotic Implant
[     ]Oronasal Fistula Repair
[     ]Oroantral Fistula Repair
[     ]Sinus Surgery


Common Pathology in the Oral Pain Patient

[     ]Gum-Periodontal Disease in Dogs and Cats

[     ]Septic Periodontitis

[     ]Oral Trauma

[     ]Tooth Fractures

[     ]Pulpitis

[     ]Oral Masses-Cysts

[     ]Tooth Root Abscessation

[     ]Enamel Hypoplasia

[     ]Gingival Hyperplasia

[     ]Caries

[     ]The Pain Hunt Patient-Multiple pathologies

[     ]The Stomatitis Dog-Chronic Ulcerative Paradental Disease

[     ]The Stomatitis Cat

[     ]TMJ Pathology

[     ]Multiple Sites-Oral Trauma Repair

Hopeless Dentition can occur from Multiple Oral Pathologies including Advanced Periodontal  Disease; Oral Trauma; Immune mediated disease; Genetic origin; Endodontic Disease; and Root Abscessation of multiple etiologies.

Periodontal disease (infection of the gum tissue and bones surrounding teeth) is a health risk which requires professional treatment by Dr. DeForge.

Gum (periodontal) disease is an infection that is a major cause of tooth loss in dogs and cats. Because gum disease is usually painless and develops slowly, the pet owner may not be aware that the infection exists.

Gum disease is caused by plaque biofilm, a sticky film of bacteria that constantly forms on the teeth. These bacteria create toxins that can eventually damage the gums and the bone surrounding the teeth.  Dogs and cats should have their first teeth cleaning by 12 months of age and then bi-yearly.  Exception to the rule is the septic oral disease patient; patients with immune mediated oral disease; the diabetic patient; the geriatric patient with multiple quadrant pathology; and breeds in which periodontal disease has a genetic linkage--i.e. toy or small breeds.  These cases are judged independently by Dr. DeForge based on re-checks.  Many need professional care every 6 months.

Without professional care, reversible gingivitis becomes............. controllable but irreversible periodontitis.

In the early stage of gum disease, called gingivitis, the gums become red, swell, and bleed easily.   There is a strong odor present in the mouth. The disease is still reversible at this stage, and can usually be kept in check with excellent homecare and cleanings every 24 months.. In the more advanced stages of periodontal disease, called periodontitis, the gums and bone that support the teeth become seriously damaged. If the disease is left unchecked, it can eventually lead to loss of teeth and major oral surgery.

The KEY to the treatment of Advanced Periodontal Disease and all Oral Pathology is CORET-Comprehensive Oral Radiology Evaluation and Treatment! 

No teeth should ever be removed without pre-extraction oral radiology.  Post-extraction dental x-rays are needed to assure that the entire tooth..... i.e. root and crown..... have been successfully removed and no root tips are left behind. 
The post-extraction dental x-ray also checks for bone sequestra [chips, pieces, or fragments of diseased bone]!  If present, these also need removal before closure.  

Pre-treatment dental x-rays can also rule out pathological fractures of the jaw caused by long present and untreated periodontal disease.

Any of the following conditions may indicate the presence of gum, tooth, or bone pathology in the oral cavity.  

They are red flags indicating the need for referral to Dr. DeForge!

• bleeding gums when playing with toys or chewing on biscuits.
• the gums appear red, swollen, or tender when examining the mouth
• the gums have receded [gingival recession] or the opposite-grown over the teeth [gingival hyperplasia]
• your pet does not want to play with toys
• your pet walks away from dry food
•  oral malodor is present or bad breath that doesn't go away
• pus visualized between teeth and gums
• loose teeth
• a change in the way the teeth fit together when biting[occlusion]
• activity changes-very important to monitor
• teeth grinding
• flipping food into the back of the mouth and not chewing
• picking up and dropping food
• multiple trips to the food bowl with little consumed
• eating canned food and refusing dry food and treats
• moaning in a remote area of the home
• excessive hyperactivity....

Remember that pain can be HIDDEN in the early stages of periodontitis or tooth trauma! This is calledBAD PAIN!

 "Bad pain" is when a patient lives with pain believing the pain is "normal"!  With no way to communicate pain, the pet advocate has to watch carefully for signs of "bad pain"!
Bad pain can be present in any oral pathology in the dog or cat!

Signs of "BAD PAIN"  in the Pet You Love!

Sleeping more

Becoming hyperactive

Pawing at their mouths

Tossing food into the back of their mouths

Grinding teeth

Hypersalivating

Walking away from food or picking up food and dropping it in front of their dish

Drinking more water

Hiding

Avoidance of play time

Crying when eating

Weight loss

It is imperative to check for co-morbidities [the simultaneous presence of two or more chronic diseases or conditions in a patient].that may be present prior to oral pain diagnostics and treatment.  

Pre-Anesthesia lab testing rules out many co-morbidities.  Other problems are only diagnosed with special imaging-i.e. x-rays, sonography, MRI's or C-Scans.

Dr. DeForge recommends comprehenisve pre-anesthesia testing to rule out and treat co-morbidities prior to initiating oral surgery diagnostics and treatment.

If CORET Diagnostics-Comprehensive Oral Radiology Evaluation and Treatment evidence areas of pathology that necessitate tooth extraction, Dr. DeForge................. with Informed Consent............. will remove the tooth or teeth that are "hopeless" or any teeth that are abscessed.  This is an important discussion prior to the day of Admission, diagnostics, and treatment. 

Leaving teeth that are badly abscessed will allow the "pain threshold" to elevate or eventually lead to systemic disease from sepsis.

Guidelines After Oral Surgery and

Advanced Periodontal Surgery!

Do’s

• Your pet must rest at home, avoiding physical activity.  Leash walk only! 
• Use Indirect Ice. Apply INDIRECT ice packs to your pet's face for 10 minutes every other hour to keep swelling down. STOP if your pet struggles!
• Feed soft foods-a blenderized diet. Stick to a liquid or soft food diet for 30 days after surgery. The first night home opt for soups; clear broth; scrambled eggs [without added fats]; yogurts, fruit milkshakes, smoothies and creamed potatoes.
• Eat foods rich in Vitamin A and C. These vitamins support the healing process. Load up on foods like scrambled eggs, blenderized fish stew; creamed sweet potatoes and stewed blenderized carrots.

Don'ts

• Leash walk only; directly supervise with an Elizabethan Collar [if prescribed by Dr. DeForge] in place 24-7 for 2-4 weeks post-surgery.  
• Check-in with Dr. DeForge about removing the Elizabethan Collar in 2 weeks.
• Don’t feed hot foods or very cold foods.
• Don’t feed hard or crunchy foods for... eight weeks post-surgery. Avoid all dry food and hard treats for 8 weeks.
• Soft plushy toys can be considered after 4 weeks if the patient is healing on schedule.
• Follow Dr. DeForge's after-care instructions to allow your pet to heal quickly without complication. 
• You should contact Dr.DeForge immediately if your pet is experiencing any of the following:

1. Pain that doesn’t respond to medication-restlessness-not eating-rubbing at the mouth-teeth grinding etc.
2. Bleeding that continues even when you apply pressure
3. A fever that lasts for more than 48 hours after surgery
4. Pus at the surgery site
5. Trouble swallowing

The Keys to Preventing Periodontal Disease; Pulpitis; and Fractured Teeth that can lead to Major Oral Surgery are listed below.  The keys are also used post-operatively to avoid further pathology from occurring.

Gum disease can be prevented by taking good care of teeth and by having regular dental checkups with Dr. DeForge that includes a complete periodontal examination and periodic updated oral radiology. 

Puplitis and Fractured Teeth can be decreased an in many cases eliminated by stopping all of the following hard chewing patterns!  The exception is accidental oral trauma.

1. Rawhides
2. Pig Ear
3. Cow Hoof
4. Antler
5. Baked-Frozen-Cooked-Sterilized-Bones of all types
6. Hard Plastic Toys
7. Hard Rubber Toys
8. Pull Ropes or all varieties
9. HARD biscuits of all types
10. Bully Sticks
11. Stopping all play with sticks and rocks

Time invested in PREVENTION of Periodontal Disease, after completion of periodontal therapy and oral care by Dr. DeForge..... with a special selection of proper chew toys..... can improve your pet's dental and general health and most importantly help minimize dental expenses. 

Aftercare is not only a way to assure healing but also is a pathway to prevent recurrence of pathology!

• Use Leba III Topical anti-plaque treatment as directed by Dr. DeForge-this is not a treatment to be initiated until after all pathology is diagnosed and treated by Dr. DeForge.  
• LEBA III is a plaque fighter but not a substitution for professional care by Dr. DeForge under general inhalation analgesia- anesthesia. This product is initiated topically 10-14 days after oral care and is continued for life.
• Keep your Periodontal and Oral Surgery Re-checks as recommended by Dr. DeForge
• Feed your pet a balanced diet. Use a quality pet food!
• Blenderize canned food for the first two weeks after oral surgery--- then blenderize dry food if you pet prefers dry food---with chicken or beef broth for an an additional two months.
• Supplement your pet's food with a variety of foods from the basic food groups, such as breads, cereals and other grain products; fruits; vegetables; meat, poultry and fish; and dairy products, such as milk, cheese and yogurt.  
• All must be blenderized.  Raw veggies must be cooked before being blenderized. Fruits can be blenderized in a juicer with vanilla yogurt to make a smoothie.  
• Ask Dr. DeForge for his homemade diets for the finicky pets post-oral surgery.
• Visit Dr. DeForge regularly. It is important to have regular dental checkups, which include a thorough periodontal exam. 
• Professional cleaning under general inhalation anesthesia is essential to prevent periodontal disease.  Remember gas inhalation anesthesia is very safe as long as pre-anesthesia evaluation is within normal limits.
• Your pet is never under "deep anesthesia"! Dr. DeForge maintains a state of analgesia-anesthesia which is considered -"light sedation"!
• When your pet is awakened; the pain control established, by Dr. DeForge, during oral surgery is continued at home. This leads to a very peaceful and expedient "wake-up" while being monitored by a telemetry nurse and a happy pet when discharged for home nursing care.
• Once your pet has been treated for periodontal disease or has undergone oral surgery, the maintenance visits with Dr. DeForge are especially important.  
• After a series of maintenance visits with complete reversal and or control of all oral pathology treated.......... Dr. DeForge will return you to your LDVM for follow-up exams.

Avoid Oral and Periodontal Surgery by Treating Gum and Oral Trauma Disease EARLY! In the patient with Periodontal Pathology this is especially important. 

Proactive Intervention v. Reactive care is a way of life! It is important in all patients throughout all stages of their lives from puppy or kitten to the gold geriatric years!

Dr. DeForge stresses the Importance o

The Complete Periodontal Prophylaxis:

Periodontal Scaling is only the beginning: Once gum disease has begun to destroy the gum and bone around teeth.............................. an ordinary cleaning will not be enough to stop the progress of the infection. 

A procedure called Supportive Periodontal Treatment-[SPT]-which is more extensive and time-consuming than routine cleaning, becomes necessary. 

It removes plaque and tartar that are causing the infection deep below the gum line. Root planing smooths the root surfaces, which allows the gum tissue to heal and to reattach to the tooth. Non-sedation periodontal care is ineffective.  It can lead to patient trauma or incomplete treatment of oral pathology.  Without dental x-rays, pathology can be overlooked or completely missed by the operator.

Major Oral Surgery and necessary Extractions are needed: 
When deep pockets of infection persist after periodontal scaling and root planing or when a pet is presented with oral trauma! Corrective surgery, extractions, or other treatments may be needed. 

Surgical treatment is designed to correct defects by reshaping or by regenerating new healthy bone. Gingiva, and mucosa must also be identified with pathology and treated accordingly.  

Extractions are only performed after confirmation of pathology with dental x-rays and with Informed Consent.  Removing infected hopeless teeth leads to a pain free quality of life.

Tooth Extraction Complications

While a simple tooth extraction does not require surgery as it is visible and easily reached.......... a broken tooth, abscessed tooth, unerupted tooth, or a tooth ankylosed to bone...... will need oral surgery to be removed from the mouth. 

How To Avoid Post-Surgery Dental Complications

Knowledge is how you win half the battle when it comes to oral health. Dr. DeForge has already explained that there can be serious consequences post-dental surgery if all medicines and post-surgery instructions are not followed!

• Follow Dr. DeForge's oral surgery after-care instructions – After your dental procedure, you will have specific care instructions to follow.
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• Some pets do not eat well for 24-48 hours post-surgery. In others, not urinating or defecating regularly after general anesthesia is common. 
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• Even if Dr. DeForge's instructions sound arbitrary, trust that the directions are given for a reason and are based on years of experience.
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• Not following post-operatory instructions will lead to unnecessary re-checks; and additional general inhalation anesthesia with additional surgery.
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• Ice pack swelling – Facial swelling is a common side-effect of dental work, and can be dealt with by holding an ice pack (or frozen veggies)~~~~~ [never use direct ice on the face or frozen ice packs DIRECTLY on the swollen area]~~~~~ in 10 minute intervals every other hour the first night home.  
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• After the first night switch to warm compresses 3-4 times daily and after meals.
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• Keep the Elizabethan collar clean and gently massage the the face with a clean wash cloth soaked in tepid water .  Food can be trapped in blood tinged saliva after oral surgery and stick to facial hairs, lips, and chin causing a dermatitis.  If this material is not gently removed 3-4 times daily with warm compressing, Dr. DeForge will have to sedate to clean the face.  This leads to additional unneeded anesthesia-sedation.

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• If  pain is suspected;i.e. there is oral malodor; or a discharge from the mouth by the 3rd day after surgery, you likely have an infection and need to be seen by Dr. DeForge.
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• Infection treatment and Pain Control-Stopping Complications –   Administer to your pet the full course of ALL medicines [antibiotics-pain medicines-appetite stimulants-probiotics and others] prescribed by Dr. DeForge.
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• Early discontinuation of medicines will lead to complications, pain, and additional surgery.  Appetite stimulants are not to be stopped if the patient is eating well. Discontinuing can lead to an interruption in appetite any where from 7-14 days after surgery.  All medicines are a total program and given for a purpose by Dr. DeForge!

Never call the Center at which Dr. DeForge performed your oral care with a progress report. Call Dr. DeForge at 1-800-838-3368 or E-Mail him at DonDeForge10@gmail.com

The only exception is when a procedure has been completed at Silver Sands Veterinary~~~~Dr. DeForge's home base. In that situation, you would contact Dr. DeForge directly at his personal dental operatory by calling 203-877-3221 and/or E-Mailing DoctorDeForge@yahoo.com

Dr. DeForge prefers E-Mail reports with Teledental I-Phone pictures of the area treated on a bi-weekly basis.  E-Mail Dr. DeForge directly at the earlier mentioned E-contact addresses.  If you cannot reach Dr. DeForge, call a local  24/7 ER Center [if it is a night or on a weekend] until you can speak to Dr. DeForge personally.

Questions:  Message to DoctorDeForge@yahoo.com