 |
Dentistry Case Study:
Fractured Tooth with Pulp Exposure
By Colleen Fox, DVM, CSAVP - Dentistry and Oral Surgery
|
History: Chase, a one year-old intact male Labrador Retriever, presented to The COVE's emergency room for evaluation of a fractured right mandibular canine tooth. (Fig. 1) His owner was unsure how the injury occurred or how long the tooth had been fractured. The initial physical exam and baseline lab work revealed nothing unusual aside from the broken tooth.
Chase was placed under general anesthesia and full-mouth dental radiographs were performed. A complicated crown fracture on the immature right mandibular canine tooth (404) was the only abnormality noted (Fig. 2). Chase's owner elected to preserve the tooth rather than have it extracted.
The right inferior alveolar nerve was blocked with bupivacaine and buprenorphine to provide 36-72 hours of local nerve control. Thorough supra- and sub-gingival scaling and polishing were performed.
Using aseptic technique, pulp amputation to a depth of 7mm was performed with a coarse diamond bur. Hemostasis was achieved with moistened paper points. A layer of mineral trioxide aggregate (MTA) was placed with an amalgam carrier. The dentin walls were cleaned gently with moistened paper points and a layer of glass ionomer was placed and light cured. Radiographs confirmed good fill. Packable composite was placed after preparation with acid etch and a dentinal bonding agent. The restoration was contoured and finished with a white stone and Shofu discs on a low-speed handpiece before being sealed with unfilled resin.
Chase recovered uneventfully from anesthesia and was discharged with 10 days of clindamycin and 4 days of carprofen. Radiographs taken six months later (Fig. 3) showed appropriate continued maturation of 404 with dentinal bridge formation and no evidence of periapical pathology. Radiographs are scheduled annually for the next two years and then whenever Chase is under anesthesia for routine dental care. Standard root canal therapy will be performed if the vital pulp therapy fails.
|
|
|
|
|
| |
Fig. 1: Initial presentation
|
Fig. 2: Initial radiograph
|
Fig. 3: Obtained 6 months post-op, showing good dentin bridge formation and increased dentin width/decreased pulp chamber size indicating a vital tooth.
|
Discussion: Treatment of Fractured and Exposed Immature Teeth
Fractured teeth with pulp exposure require either exodontic (extraction) or endodontic treatment. Immature teeth are not candidates for standard root canal treatment due to wide pulp chambers, thin dentin walls, and often an open apex.
Vital pulp therapy (partial vital pulpectomy) is the endodontic treatment most often recommended for immature teeth. Success rates depend heavily on the length of time between fracture and treatment, with success rates approaching 95% when pulp exposure is created surgically. If VPT is performed within 48 hours of pulp exposure, the success rate is around 88.2%. The rate goes down to 41.4% after one week and 23.5% after three weeks. Since we didn't know how long Chase's tooth had been fractured, his owner was given a guarded prognosis for successful treatment.
Compared with standard root canal treatment, which involves removal of the entire pulp chamber, only the most coronal 6-8 mm of pulp is removed during VPT. Mineral trioxide aggregate (MTA) is placed over the pulp stump to stimulate the odontoblasts to produce tertiary/reparative dentin. Additional restorative layers of glass ionomer and composite are then placed to seal the tooth against bacteria that would produce pulp necrosis. Since the bulk of the pulp remains intact, normal secondary dentin production continues, and the tooth becomes stronger.
Recheck radiographs are required to confirm continued maturation of the tooth (as evidenced by the pulp chamber size decreasing over time), to confirm the formation of a dentin bridge from apical to the MTA, and to assess for periapical bone loss or root resorption.
|
|
|
|
TECH TIP: Steadying Radiology Sensors
By Taylor Redmond, LVT
|
|
|
When taking intra-oral radiographs, it is important to practice radiology safety, but this can be difficult when the sensor won't stay in place. Instead of holding the sensors to keep them from moving (exposing yourself to dangerous radiation), paper towels or gauze can be used. We also can use small towels to lift the patient's head in order to get radiographs of the mandibular teeth.
|
|
|
|
DID YOU KNOW?
The Importance of Dental Radiography
|
|
We believe radiographs are vital to every dental procedure. At The COVE, each patient placed under anesthesia for a dental procedure has a full set of dental radiographs performed before we begin, so our team has a clear view of the problem. After the procedure is finished, we take another set of X-rays to confirm complete removal of roots after extraction and proper fill of teeth that underwent root canal therapy. We also use dental radiographs to assess for progression of bone loss when patients return for follow-up procedures. |
_______________________________________
Congratulations Are in Order!
Our outstanding veterinary dentistry team has worked hard to earn new and distinguished certifications:
|
|
|
Colleen Fox, DVM, CSAVP, earned a Certificate of Small Animal Veterinary Practice/Dentistry.
Dr. Fox earned her certificate through the University of Luxembourg in cooperation with the European School for Advanced Veterinary Studies (ESAVS). The CSAVP testifies that an intermediary level of theoretical and clinical competence (defined by leading European veterinary organizations) has been obtained in a chosen discipline. We are very proud of Dr. Fox for working so hard to achieve this incredible honor and milestone in her career and practice.
|
Danielle Martin, LVT, earned a VTS (Veterinary Technician Specialist) in Dentistry.
This prestigious certification is issued by the Academy of Veterinary Dental Technicians and is awarded to credentialed veterinary technicians who complete a rigorous two-year process of education. Danielle is our veterinary technician dentistry team lead. We're so proud of her fantastic achievement and for bringing more experience and knowledge to our dentistry department. |
|
|
|
|
NEWS YOU CAN USE
Our New EMR System
|
|
Coming this spring, we'll be upgrading our electronic medical records (EMR) system. Instinct EMR is an easy-to-use portal that allows you to seamlessly make referrals, retrieve updates, and share patient documents.
When a mutual patient arrives at The COVE, your information, including email address, is entered into Instinct EMR. From there, Instinct Shareville automatically notifies you via email that one of your patients has checked in or checked out of Instinct.
|
We hope that this new streamlined process will make referrals and sharing information easier than ever. Stay tuned for more details!
|
|
|
|
|
Goodbye and Thank You to Our Criticalist, Dr. Jaqueline Nobles
|
|
After four years of dedicated service, Dr. Jacqueline Nobles will soon be leaving us. Over the next several weeks, we will be working to make this transition as smooth as possible, including conducting a search for a board-certified emergency and critical care specialist. Our goal is to maintain the high level of ER/CC care for which The COVE has become well known. We will keep you informed of our progress.
|
If you have any questions, please do not hesitate to reach out to Danielle Russ, Hospital Manager, at 757.935.9111.
|
|
|
|
|
24/7 Emergency and Critical Care | Surgery | Cardiology | Dentistry
|
6550 Hampton Roads Pkwy, #113 | Suffolk, VA 23435
P: 757.935.9111 | F: 757.935.9110 | thecovevets.com
|
|
|
|
|
|
|
|
