Young Dogs & Tooth Fractures: Modern Treatment Options with Dr. Sandra Manfra Marretta

What should you do when a young dog fractures a tooth that is still developing? Is extraction always the best option—or can these teeth actually be saved?

In this episode of the Pawsitive Veterinary Dentistry Podcast, host Benita Altier, LVT, VTS (Dentistry) sits down with Dr. Sandra Manfra Marretta to discuss one of the most important and misunderstood topics in veterinary dentistry: the management of immature permanent teeth with crown fractures in dogs.

Dr. Manfra Marretta is a Diplomate of the American College of Veterinary Surgeons, a Charter Diplomate of the American Veterinary Dental College, and an AVDC and ACVS Founding Fellow in Oral and Maxillofacial Surgery. Drawing from decades of experience in veterinary oral surgery and her published review paper on this topic, she shares practical insights that every veterinary professional can apply in practice.

In this episode, we discuss:
🦷 Why immature permanent teeth are different
🦷 Vital pulp therapy and treatment options
🦷 Decision-making for fractured teeth in young dogs
🦷 Common mistakes clinicians still make today
🦷 When teeth can be saved—and when they cannot
🦷 Client communication strategies
🦷 Practical tips for veterinary teams in general practice

Whether you are a veterinarian, veterinary technician, student, or someone passionate about veterinary dentistry, this episode delivers valuable clinical insight into improving long-term outcomes for young patients with traumatic dental injuries.

Research Article

https://sage.cnpereading.com/doi/10.1177/08987564211046325

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Transcript

SPEAKER_01 0:00

Hi everyone and welcome back to the Positive Veterinary Dentistry Podcast, where we bring you real conversations with leaders in veterinary dentistry to help you elevate patient care, improve outcomes, and grow your confidence in clinical decision making. I'm your host, Benita Altier, licensed veterinary technician, veterinary technician specialist in dentistry. Today's episode is one that I think every veterinary professional, especially those in general practice, need to hear. We're diving into tooth fractures in young dogs, specifically those immature permanent teeth that can be incredibly challenging to manage. Today I'm truly honored to be joined by Dr. Sandra Manfra Moretta, a pioneer in veterinary oral and maxalfacial surgery and one of the most influential voices in our field. Dr. Manfra Moretta received her Doctor of Veterinary Medicine degree from Cornell University and went on to complete an internship, surgical residency and clinical dentistry training at the Animal Medical Center in New York City. She's also a diplomate of the American College of Veterinary Surgeons, a charter diplomate of the American Veterinary Dental College, and an ABDC and ACBS founding fellow in oral and maxillofacial surgery. And these are distinctions that truly reflect her leadership and impact in shaping the specialty. Dr. Mantra Moretta has also contributed extensively to the literature, including her important publication, Decision Making and Management of Immature Permanent Teeth with Crown Fractures in Small Animals, which is exactly what we're going to dive into today. So, Dr. Mantra, welcome to the podcast. It's such a privilege to have you here.

SPEAKER_00 1:39

Well, thank you. I'm so excited to be here. This is my first episode with you, and I'm I'm very excited to be welcomed here.

SPEAKER_01 1:47

Yes, absolutely. And we are really excited to have you. And honestly, I hope to have you back to do more because we're going to talk about some things we're working on together, you and me, to bring more information to general practitioners and technicians and teams out there. But really importantly, you have so much experience in oral maxillofacial surgery beyond just being a veterinary dentist, and so many concepts that I feel will really help our general practitioners understand this a lot better. So really excited to have you here. There is a tradition with the Positive Veterinary Dentistry Podcast. My last guest on the podcast, Dr. Maria Soltera Rivera, left a question for you. And this is a fun question that we get to answer just to start off the episode. And at the end of the podcast today, you will be leaving a question for my following guest. So, Dr. Manfra, this question is looking back in time, what concepts in veterinary dentistry did we get most wrong early on? And what are we still getting wrong today?

SPEAKER_00 2:54

Oh, okay, that's a good question. I I think probably how to deal with frication lesions in dogs. Okay. And what even many veterinary dentists said if you have a frication lesion, you should extract the tooth. Okay. Because it had a poor prognosis. And we wrote another paper about how that's not necessarily true. And even in the humans, they change their philosophy. So that's something that I think is important that veterinarians know that just because a dog has a frication lesion, even like a grade three, that doesn't mean that the tooth needs to be extracted.

SPEAKER_01 3:38

Very good. And I think that's still so relevant today. So her question, what are we still getting wrong today? I don't think most people really know this or think about this, that there are options to saving these teeth versus what I like to call toothanasia, where we're having to and often we're dealing with some very large, solidly rooted teeth with vocational exposures that we certainly don't want to have to extract if there's any alternatives. We're going to do another deep dive into that particular topic in the future. We're planning for a webinar that people can sign up for and get CE credit. So we will table that topic for now. But what a great question from Dr. Soltera Rivera that really is a segue into what we're going to talk about in the future regarding forcation lesions and how to hopefully not have to extract teeth. Before we dive into the clinical side of things with what we're going to talk about today, I always love to start with your story. And everybody has a story, but you've had such an incredible career spinning surgery, dentistry, education. When you look back, did you ever imagine how the field of veterinary dentistry would evolve and the role you would play in shaping it? Tell us a little bit about your story and how this all happened for you.

SPEAKER_00 4:55

Well, okay. Well, that this is quite a story. And I love telling it because I think it was serendipitous that I ended up where I did. I always wanted to be a veterinarian from when I was 12 years old. And I had a hard time getting into vet school because the only vet school in my state was Cornell at the time. And you weren't allowed to apply to other states if you had a school in your own state. And they were only accepting 60 people a year, and they would only accept two women a year because they said that's all there was room in the dormitories for two women. Well, I think that changed fortunately uh during my time. It was in the early 70s that I first started to apply, and I applied three times. And fortunately, the third time I was able to get in, and there were about eight women in my class. Wow. So that that was really exciting. And then I wanted to be a surgeon, so I went to the animal medical center, did my surgery residency, and then I went into private practice for two years because I started a family, but I missed the animal medical center. And I went back to the animal medical center. And at my first staff meeting, they said, Who would like to learn how to do a root canal? And I thought, oh, that's that might be interesting. So I raised my hand and I looked around and nobody else was raising their hand. In fact, they were kind of slinking down in their seats. And I started to take my hand down because I'm thinking, well, maybe this isn't such a good idea. And the uh the head of the hospital said, Mamphra, you're the new dentist. But they hired Mark Tholan, who's a human dentist that worked in San Antonio at the base, who did all their uh root canals, and they've hired him to come and train me once a month for a week for about 16 months or so. And that's how I got my clinical training in veterinary dentistry. We would see 30 to 40 cases a week, and we would do root canals and all different types of jaw fractures, all different types of surgery in the oral cavity. That's how I got my clinical training. And then in 1986, I think that's when the academy was formed, and I became a charter member of the academy after the first test. And then they formed an organizing committee for the dental college, and I was selected to be on that organizing committee. I was the only woman in that group, and uh, and I think the only reason I happened to get picked is because there were other more qualified people, but because I had my ACVS diplomat status, they felt that I would add to the oral surgery component. And then then I was recruited to the University of Illinois, and I taught there for uh 23 years, and then I retired, but I'm still working part-time at the U of I to continue helping them educate their students every part-time. And then I also do these different meetings with the different groups.

SPEAKER_01 8:14

Oh my goodness, that's amazing. I had no idea that it well, I did have an idea, I guess to some degree that women were really frowned upon in veterinary medicine in general, and that you were limited based on the number of rooms in the dormitory. That's just crazy looking back at that. But now we've come such a long way where the majority of veterinarians are women, and it's just amazing that you were able to persist and not give up on your dream, always wanting to be a veterinarian. And then, you know, that story about you raising your hand, I love it because you weren't turning away opportunity. You're like, wow, that sounds really interesting. Maybe I'll try that. So you don't say no to things, which has been my philosophy as well. If I'm given an opportunity, I better take it. And I found that that really has served me well in being able to advance my career and always having sort of an outlook on life that you want to learn new things, and that really helps. And in the end, the patients that we want to take care of, right? Help me.

SPEAKER_00 9:27

Yeah, it was the best decision I ever made. You know, it really expanded my career so much.

SPEAKER_01 9:33

Yes. I also feel that way about getting my vet tech specialty in dentistry, best decision I ever made. And even to this day, you know, we have some people who say, wow, it's so hard to get a VTS, but it's not meant to be easy. It really is meant to help you learn and to be qualified to be a subject matter expert in your field and you know, give you the title that you're looking for, yes, but definitely it's not easy. But that's okay. Good things come when you work hard, persisting and not giving up. Right. So, what a great story. Well, we'll have to hear more of your stories as we go through this episode here, because I love to hear things that happened in your life and how that kind of shaped the person that you are today, and even writing the paper that we're gonna talk about today. So, we're gonna start with the big picture. So, in a general practice setting, we do see a lot of tooth fractures in young dogs as well, not just dogs that are mature, whether it's from them chewing on something that their well-meaning pet parent gave them, like bones or rocks or sticks they might find outside, or even things that are actually very expensive to buy at the pet store, like antlers, things that you'd think are everlasting chew toys, but unfortunately they're tooth destroyers. When you think about, from your perspective, why immature permanent teeth are so unique and important category to discuss, what specifically do you think about if a young dog has a tooth fracture that makes these teeth unique or biologically different than a mature dog that gets a tooth fracture?

SPEAKER_00 11:18

Okay, so in young dogs, say less than maybe seven months old, their apex is not closed. And if the apex is not closed and the tooth fractures and dies, the apex will never close. The other thing is that the tooth is very fragile when a dog is young. So when the tooth first erupts, the dentin is very thin and it's more prone to fracture. And I think that's why young dogs end up breaking their teeth more often, just like children, because number one, they're doing things crazy that maybe they shouldn't be doing. And number two, that the dentin is thin and more prone to fracture. And and then if the tooth fractures in a young dog, it doesn't grow to its full length. So you have a very short crown to root ratio. So it's important if an owner notices a young dog gets a fracture when it's young, it should be brought to the attention of the veterinarian for treatment because the sooner that young dog's fracture is treated as appropriate, the better the prognosis.

SPEAKER_01 12:34

Right. And often, like you said, young dogs are roughhousing. They are crazy, they're just playing with other pets in the family or things, they pick up everything with their mouth, they put everything in their mouth, and the teeth are actually much, much more fragile because of the walls of dentin being so thin. Also, they just barely erupted. So, dogs that are getting their adult teeth, whether it's a canine or a maxillary fourth premolar or mandibular first molar, these teeth are the ones that they really use in more of an aggressive way to either bite down on something or the canines being right up front in their mouth are more prone to being fractured as well. When we think about how quickly we need to be aware that this tooth is fractured so we can treat it, what would a client maybe notice that would even clue them into the dog fracturing its teeth? Because don't these go unnoticed quite a bit?

SPEAKER_00 13:39

Yes, it's true. They go unnoticed. So one of the things is the history associated with the fracture. And obviously, if the animal got hit with a baseball bat or a golf club by mistake or was hit by a car, that is the time to really look in the mouth and obviously probably take them to a veterinarian if there was some kind of trauma to the mouth, to make sure there's no fractured teeth or a fractured jaw. The other thing, though, like you said, it could be an incidental finding and it could be that, you know, the dog was chewing on a uh a hard object and fractured a tooth. So if an owner sees any blood coming from a tooth, obviously that's a really big red flag. The other thing that the dog might show is some evidence of discomfort in the oral cavity. So they may prefer not to chew on their too hard chewed toys, or maybe not wanting to eat dry food for maybe soft food, or if they drink cold water, they might jerk back and be in a little discomfort, or you know, their appetite might not be off. But that's a hard thing to really see in animals because they're so food motivated they might even eat through that. So I think the big thing is number one, avoid the fracture to begin with by not giving those hard chewed toys. And number two, if there is an episode of trauma, that oral cavity has to be examined because the chances of them having a broken tooth or a broken jaw could be pretty high. And so the sooner, especially in the young dog's tooth, the prognosis is better if you get treatment sooner than later. And we're talking about within anywhere from hours to a few days, and it could be successful, even up to they say three weeks, but the sooner the better.

SPEAKER_01 15:44

Yeah. So I feel that owners of dogs, because we're mostly discussing dogs today, if they're getting in the mouth of their dog to do something like brush the teeth, they may be more likely to notice a tooth fracture really as soon as it happens or within 24 hours. My daughter has a yellow Labrador and she brushes her dog's teeth every single night. And of course, I'm very proud of her for doing that. But the other bonus of brushing the teeth every day, besides keeping gendivitis at bay and keeping the teeth clean, is that she's getting in there and looking around. And when her dog was a puppy, she actually did break one of her baby canine teeth. But my daughter realized it the very day that it happened. So that was timing was really critical in situation, whether it's a deciduous or baby tooth that's fractured or an adult tooth. But we're gonna talk about specifically if this fracture is discovered, whether at home, and then the dog is taken to the vet within a short period of time so that we can decide what to do about this, or if there was some trauma, the dog yelped. If a dog is chewing on something and yelps, or was playing really rough and yelps, or that's a real big clue that the client needs to bring the dog to the vet. It shouldn't be just ignored that it's something not to worry about, because then we can look in the mouth. Veterinarians out there definitely, when they do their examination of patients that have a history of doing something that reacted in pain but now seems fine, we should definitely be looking in the mouth and checking things out and making sure that there's nothing stuck in the mouth or is something like a tooth fracture. So when we think about these young teeth, they're still in the process of developing, even though the enamel has formed on the crown and the tooth has come into the oral cavity. What can you tell us specifically about how these teeth develop and what happens when the pulp is exposed on these young teeth? What is it that's happening in there that we're so worried about that needs treatment?

SPEAKER_00 18:02

Okay, so when the as soon as the tooth erupts, only maybe 50% of the root is formed. So there's a lot of tooth development that has that occurs after the tooth first erupts. And that tooth is a shell of a tooth when it first erupts. It's got obviously the enamel on the crown and dentin underneath the enamel, but the pulp chamber and the root canal is very, very wide. And it takes probably until they're 18 months to reach the level of dentin to make the tooth at least strong relatively strong. Obviously, we can continue to deposit uh as the dog ages, but we what we ideally like to do is at least keep the tooth alive until the dog is 18 months of age.

SPEAKER_01 19:01

Okay, so part of this is that the tooth is at risk of dying if it has pulp exposure.

SPEAKER_00 19:08

Exactly. So and this is uh another point that I just found out just recently. So if the pulp is exposed and then you're gonna get pulpitis once the pulp is exposed. Once you get pulpitis, the next thing that can happen over the next uh three to four weeks or so, it undergoes irreversible pulpitis and then pulp necrosis, and that's when the tooth is dead. And once that tooth is dead, bacteria obviously get into the tooth and it can come out the apex and then cause draining tracts, periapolysis radiographically, facial swelling, osteomyelitis, a lot of pain. So the key is to try to keep the tooth alive by treating the tooth before we end up getting irreversible papitis and tooth necrosis. And there's a whole series of things that can be done depending on the amount of trauma to the pulp. One thing I did learn, I spoke to the co-author of my paper, my former resident, and I said, I just wanted to let her know that I was going to be giving this webinar. And I uh she says, Oh, Dr. Manfred, I have come across another paper that you may not know about that was published after we wrote the paper. And sure enough, I I she sent me the paper, and I was amazed what it said was that about 22% of teeth that are fractured without pulp exposure die and their pulp becomes non-vital. And that was an eye-opener for me because I knew that could happen, but I didn't know that the percentage was so high. So whenever you see even an uncomplicated crown fracture where the crown is fractured but the pulp's not exposed, it could lead to pulp necrosis. So something that we have to think about. Yeah.

SPEAKER_01 21:13

Yeah. We talk about this, and people think, oh, especially in a mature adult tooth, it's an uncomplicated crown fracture. They're like, we can't explore into the pulp. And they think in those cases that they're scot-free home because they don't need to treat or do anything, and the tooth's not at risk of becoming irreversibly damaged by that what you called irreversible pulbitis that leads to pulpal necrosis. But the dentinal tubules will allow bacteria from the oral cavity into the inside of the tooth. And it's certainly at more risk of death. And now we know 22% of those teeth that have uncomplicated crown fractures go on to get irreversible pulpitis and pulpal necrosis. And then potentially that's it for that, too. That's great to know the statistics and that we should be more aware. I think with these young patients, what a lot of people don't appreciate is how close the pulp chamber is to the dento enamel junction because the dentinal walls are so thin, it doesn't take much of a fracture to expose the pulp. And the likelihood of that dentinal wall being so thin as well would certainly allow bacteria from the oral cavity to invade into the pulp and set up shop inside the tooth and start to create that necrosis type of effect pretty quickly.

SPEAKER_00 22:43

And what I in that paper that we wrote, we did say that the dentin is more porous in dogs than in people. And in people, what they claim is that if there's a half a millimeter of dentin left, that's enough to maybe protect the pulp. And then obviously they would do treatment on that, but they it's likely that it wouldn't undergo irreversible pulpitis. In a dog, because the dentin is more porous, the level of dentin that needs to be present to help maybe not go towards irreversible pulpitis would be anywhere from one to two millimeters. So that's maybe up to four times more dentin that you need in a dog to help prevent irreversible pulpitis versus a human.

SPEAKER_01 23:35

Wow, that's good statistics to know as well. So when we think about a dog that's between, let's say, four and seven months of age, because that's when they're getting their adult teeth in. At what age do dogs actually have what we would call mature adult tooth, where the apex is closed and the dental walls have some thickness so that the tooth becomes a little bit more robust?

SPEAKER_00 24:02

I would say nine months of age where the apex should form, depending on the tooth, obviously. And uh there's papers written on that when the apex closed. By nine months, the apex will close, but the dentin is narrow and the pulp is very wide, and the tooth is still weak. So until 18 months of age, we should make every effort to keep the pulp vital.

SPEAKER_01 24:26

Exactly. And dentin will continue to lay down throughout the patient's life, right? So that the dentin will be able to do that. Right.

SPEAKER_00 24:35

And to the point where you get a sclerotic canal where you can't even see hotly the canal. And it depends on how active that dog is in chewing, how quick that dentin will lay down.

SPEAKER_01 24:46

So the goal here is to recognize that there has been a breach into the pulp chamber via some sort of damage to the tooth, whether it's a fracture, or I do have a story about a nine-month-old yellow lab that also had been given a tennis ball and had open bleeding pulp because of abrasion. Yes. So, same kind of thing, the pulp so close to the surface. The dog loved his tennis ball. It only took three months or less for that pulp to be bleeding and open on all four maxillary and mandibular canines. And so the treatment for that is not different than what we would talk about if it's a tooth fracture. But we have to be really careful what we give these young dogs because of the risk of damage to the teeth that can lead to the tooth's death, and especially if it's not recognized early enough that they could get in and have the options. So, one of the things I really appreciate about the paper that I'm going to link in the show notes on this particular topic is that you really do a great job of outlining the decision-making process. So let's talk about when you as a veterinarian, and you know a lot of stuff because you are a dentist and you know a lot about oral maxillofacial surgery. But for a general practitioner, when they're seeing this younger patient maybe presenting with a history of sudden pain in the mouth, or the owner noticed a tooth fracture, or maybe no history at all, what kind of things should we be thinking about when we think about the decisions that need to happen regarding treatment for a tooth that we notice is fractured?

SPEAKER_00 26:26

Well, we we need to number one, know the history of what happened. Clinical exam, you have to see how many teeth are fractured. Is it just one or more? See the extent of the fracture. Is the fracture just very superficial or is it near pulpal exposure, or is there pulpal exposure? And then you want to take a dental x-ray to see if there's any evidence of non-vith, such as periapolysis, and also on physical exam, look for draining tracks and look for facial swelling. Mm-hmm.

SPEAKER_01 27:05

And so this sounds like these pups need to go under anesthesia because young animals, especially, might be kind of wiggly and hard to look at. So we want to get them under anesthesia so we can really do a thorough clinical evaluation and take the dental x-rays. And when you say look at it with a dental x-ray and look for something that's going to be a red flag, what when you look at dental x-rays specifically, are you thinking about when it comes to a tooth that's obviously fractured on the crown? You can see it with your eyes, touch it with your instruments. But what are you looking for? Because I assume there's some specific things. Okay, sure.

SPEAKER_00 27:44

So it if you have an acute fracture, you're probably not going to see a lot of radiographic changes if the tooth is still vital. Although you might see evidence of part of the tooth missing, but you could see that on your oral exam with your dental explorer. But what you're going to see is if the tooth is non-vital, like, say, for example, you're doing your exam, you see a fractured tooth, you get your explorer in there, you probe the tooth and it doesn't bleed and it's black, that means a tooth is non-vital. Now you don't know how long it's been non-vital, but you can take an X-ray and that'll give you an idea of how long the tooth might have been non-vital. So, for example, if the tooth fractured years ago when the dog was young, and you take an x ray, what you'll see is when you compare it to the contralateral tooth, the tooth will have a much wider pulp canal and a very narrow dentin. The tooth apex may be open, and the crown to root ratio would be shorter because the root didn't grow to its full length. And then you might also see osteomyelitis in the surrounding bone. And then obviously, on physical exam, you could surely see a draining tract. And if you're going to see a draining tract secondary to fractured tooth or endodontic disease, the draining tract will often be apical to the mucogingival line. Whereas if you have a draining tract secondary to periodontal disease, it'll be coronal to the mucogingual line. Or sometimes it's right at the mucogingal line, and you'll have to base your clinical exam, like periodontal probing, to decide for sure what it is. And you could always put a gutter percha point, which is a radiopaget, peg almost like a toothpick side structure, into the draining tract, and it'll point to where the draining tract would be arising from. And that would be in a fractured tooth, it would point to the apex of that tooth. That's great.

SPEAKER_01 29:56

Because we want some real understanding of how we can diagnose this to understand what we should do about this or if it's a good candidate for referral. Most veterinarians out there are not doing vital pulp therapy, which we're going to talk about, or traditional root canal therapy. And so they need to understand is this tooth a good candidate for this or is it not? And I would assume if the patient is young, we know the age of the patient because the owner's giving us that history. And we also can tell that by the dental radiographs because we can tell a little bit better about looking at all the teeth and their level of maturity. If they're all maturing at the same rate, they're all basically presenting as being the same age, right? But if a tooth stops maturing, i.e., the dentinal walls don't get any thicker. I always say the teeth are frozen in time if they die, then that tooth stands out against the contralateral tooth, as you mentioned, because of the subtle but sometimes marked difference in the dentinal wall thickness and the root canal thickness as well. So, first of all, we have to establish what is it that's injured, the stage of root development at that particular time, and is this tooth still alive or has it already perished, right? Right. So when we think about that with these young patients, why is it so important that we do something soon and quick and specific so that the tooth can stay alive rather than wait until the tooth dies and do something about it with these young patients and their open apex?

SPEAKER_00 31:40

Well, the prognosis is much better the sooner treated than later, because once the tooth gets irreversible pulpitis and the tooth dies, it's much more difficult to treat. And the prognosis for getting full strength to that tooth is very poor. So the key is to treat it as soon as possible, keep the tooth alive as long as you can, and let the tooth develop to its full potential.

SPEAKER_01 32:12

Okay. So the idea is we want to keep the tooth in the patient's mouth, and often these are big, important teeth we're talking about. If it was just a little O5 premolar or an incisor or something, we might not be as excited about trying to spend a lot of money and heroic efforts to save the tooth, but often these are canine teeth or the carnassioles, right? So we really do want the tooth to be there for form and function. When we have a young patient that's between six months and nine months, they still have that open apex. What is our treatment option? What should the clinicians know about what a veterinary dentist would be doing if they were trying to save a tooth that's fractured?

SPEAKER_00 32:58

Okay, so it depends again, the level of fracture. So if it's just a very superficial fracture, we just need to do minor restoration of that tooth. If it's near pulpal exposure, we need to do the next level of treatment where we maybe put in some MTA and some restoration of that tooth. However, we might even do uh vital pulpotomy on those. And vital pulpotomy usually is done on a young dog's teeth or even or older dog's teeth that have a recent pulpal exposure, where the tooth we hope has reversible pulpitis, and we can remove a portion of the pulp, the damaged pulp, the very superficial part, maybe seven or eight millimeters or so of the pulp, and then put a dressing on that, usually MTA, and then we can put maybe a layer of glass ionomer and then a restorative material on top of that. So the whole point is to remove the disease pulp with a fracture occurred, several millimeters of that, like maybe eight or nine millimeters or so, put a dressing on it, restore it, and then the tooth remains alive and the tooth continues to develop, get the apex forming more dentin laid down. Now, if we don't get it in a soon enough time frame where the pulp is now necrotic, there is other treatment that can be performed, but it's not, it doesn't have as great a long-term prognosis for new dentin deposition as it would be if you got it while the tooth was alive. So that's the urgency is to get to the tooth, treat it so that the tooth can remain alive and continue to develop. Right.

SPEAKER_01 34:51

And especially if the root apex isn't even formed. Just because I don't know if everyone understands some of the terminology, can you explain what the purpose of MTA is and what that actually means, those letters?

SPEAKER_00 35:08

Okay. So MTA, mineral trioxide aggregate in the veterinary field, relatively new, maybe 15 years, but they've been using it in human dentistry probably for 25 years or so. And they used to use calcium hydroxide. What it does is it kills the bacteria that are in the pulp, and it causes the dentin, lays down a layer of dentin below that dressing, and then it allows the tooth to continue to hopefully remain alive so that more dentin can be laid down. So the whole point of that dressing is to it's almost like a medicant on that tooth to help prevent that tooth from dying. And we used to use calcium hydroxide for that, but after we started to use MTA, I think it was maybe six times or so, four to six times more successful when you used the MTA minal trioxide aggregate. And I I have to tell you, when before we had that product, I hated doing uh pulp caps because my my success rate was not that great. Once I started using MTA, I I can't remember having, I'm sure I've had a failure that I don't know about, but it was much, much higher success rate with that product. And people were happy with the results. And uh, we didn't have to go back and then do a root canal on that tooth because the pulp cap was a successful and the tooth remained alive.

SPEAKER_01 36:52

Yeah, I've heard that described as the MTA kind of creates a little bit of irritation, too, which stimulates the dentin to lay down a bit of a ceiling there at the most coronal portion of that tooth at that point to wall off the outside world from the pulp that we want to keep vital. Does that sound correct? Like it's sort of yes, that's a good way of describing it. Very good. Okay. And then what's the purpose for the glass ionomer on top of the MTA before you do some sort of a composite restoration?

SPEAKER_00 37:28

I think what the purpose of that is it helps you to compress the composite material rather than driving the MTA down into the canal, because that is one reason for failure. If you push too hard on that MTA and it gets into the canal, it can irritate that deeper pulp and cause it to become non-vital potentially.

SPEAKER_01 37:51

And I think I read that in your paper, the research paper, about that particular thing, because we have to be very delicate in this technique in order to hopefully not make it worse and the tooth tries to die, even through our best efforts. But a percentage of the teeth that are treated with vital pulp therapy, which is what we're talking about here, trying to keep the teeth alive so that the root canal can continue to be vital and we get dentinal deposition and get the tooth to be thicker walled and stronger and a complete root tip apex, as well as making sure that the tooth lengthens as it should. What percentage of vital pulp cases do you think actually are successful when it comes to these types of treatments on young dogs?

SPEAKER_00 38:42

Okay, so I'm thinking that in that paper that we wrote, we reference an article that came out of the University of California with Dr. Frank Frostrati's group. And they had over a hundred vital polpotomies that they did. And I think they found that it was more successful with the MTA versus the calcium hydroxide. And if I remember correctly, maybe you would remember, I think it was greater than 90%, wasn't it? In that paper. It's a pretty high percentage. Yeah, I can't remember if it's 90%, but yeah, it was a high percentage. It was a high percent. And I think the key was once we started using the new products versus the calcium hydroxide, we got much better success rate. And the same thing was true with humans.

SPEAKER_01 39:27

Yeah, dentistry's come a long way. And we can learn from all the case examples in human dentistry, since it's so much more prolific and longer standing research on human dentistry, what products would be best to use in our veterinary patients. So if we have a patient that did have a fractured canine, let's say, and the dog is six months to nine months of age, and the fracture is realized by the owner and it's taken to the general practitioner, and that practitioner has listened to this podcast and is, oh, I heard about this thing called vital pulp therapy. And that means that a veterinary dentist could potentially keep this tooth alive, go ahead and seal it off so that it can continue to live and mature and get stronger. And this could be a saved tooth, then we've got all the stars aligned, and that dog then goes to the veterinary dentist and gets the procedure done. And we know that if all those stars align, we have a pretty darn high success rate with being able to keep this tooth in the mouth on being able to have that dog not have pain infection. If stars don't align, though, and the fracture is not recognized, and then the tooth dies, is there anything that really can be done at that point? If maybe we do have a perilous draining tract at this point, maybe right at the mucogenival line, and now the dog is a year and a half of age and the tooth's been basically dead for a year. What could be done at that point, if anything?

SPEAKER_00 41:02

Okay, so if the owner was very motivated to save that tooth, say, for example, he's a show dog, they need to maintain that tooth, there are treatments for non-vital, permanent young teeth to save those teeth. And if it would be what one of the procedures is called an apexification technique, where they would put MTA or calcium hydroxide in the tooth, have an apex ultimately form, and do a conventional root canal on that tooth. The problem is that's going to be a weak tooth because the dentin is so thin that it may very well fracture. And there's another new technique where they can keep the tooth alive by over-introducing a file into the tooth through the apex, causing bleeding in that tooth, and then maybe get a little bit more dentin developing and restore the tooth. But those are a little bit more, it's much, much better to treat the tooth when it's young and still alive, because the prognosis for treatment is much better because you have continued development of your dentin.

SPEAKER_01 42:19

Is that what you're describing? Stimulating the tooth to, I don't know, if it could be regenerative, the pulp, but surgical endodontic procedure?

SPEAKER_00 42:31

Is that what we're talking about? No, it's called regenerative endodontics, and that is in its infancy in veterinary care. Christine Fagan wrote a nice article, and that's referenced in our paper, and that's where it's a young tooth that apex is open, and what you do is you go in, you clean out all the dead necrotic pulp, and then you over-instrument, of course, bleeding into the pulp, and then you restore MTA on top of the bleeding, a layer of glass aonomer composite, and and that actually can stimulate new dentin to form. But the one case that she reported on in her paper, the tooth ended up fracturing again because it the tooth is so fragile. And they ended up extracting the tooth. So unless the owner is extremely motivated to save that tooth, it extraction may be a relatively good option for a tooth like that. Because when it's so young and dead for a long time, the prognosis is not nearly as good as if you get it. When they're young, the tooth is still alive. Prognosis is excellent.

SPEAKER_01 43:53

That's really cutting edge research there and really exciting. I'll have to read that article and read more about this.

SPEAKER_00 44:00

It's very interesting and they are using it in people, but even in if I remember correctly, the statistics in children that they did this with I think it was something like maybe 30% of those teeth went on to fracture because they never developed and they were weak.

SPEAKER_01 44:18

Yeah. So what would you tell a pet owner to do after a vital pulp therapy to make sure that the tooth, because it still is thin dentinal walls and we're hoping that it will stay alive and we don't want it to fracture again? What would you tell them to be aware of to do or not to do when it comes to their food or anything that they're chewing on or playing with? Or I would I would tell them to avoid any hard chew choice.

SPEAKER_00 44:49

So, you know. What fractured the tooth in the first place? I'm sure what fractured the teeth in the first place. Nothing hard. I mean, I think they can have a normal, relatively normal diet, but nothing, no sticks, no stones, no antlers, no nylon, no, nothing that you can't indent with your finger. I would avoid any hard chew toys. Obviously, avoid tugging of war and roughhouse playing, things like that. And you probably have recommendations for certain chew toys that you would recommend.

SPEAKER_01 45:23

Yeah, it's hard to have things that are gonna be everlasting and not be edible because the things that are gonna be durable that people want to give their dog to chew on tend to be things that when the dog bites down hard causes tooth fractures or tooth damage. But even more important if a tooth has been damaged, that they can't give them things that would risk the tooth more and/or other teeth in the mouth. And that doesn't mean necessarily forever, but if a dog is five years old and has really thick dentinal walls, nice strong, fully formed teeth, their teeth can withstand just a lot more of their bite-down and chewing forces than these young dogs with these more fragile teeth. So good advice in general with young animals is to be very, very cautious what you give them to chew on because of the fact their teeth are just so fragile and avoiding the tooth fracture in the first place is the most important part. And then on top of that, if a fracture occurs, recognizing it as soon as possible to get them into the vet while the teeth's still alive. It's emergency. We need a tooth ambulance, get me to the vet because if you don't, I might die. And there's other things that happen too where teeth are bulsed or teeth luxate. We could have a whole episode about things like that happen to teeth that we need to have more of an emergency. A lot of things in dentistry are not emergencies because it's things that have gone on for years to cause problems like periodontal disease, but this particular subject really is the chief emergency where we want to get them to the vet. And the vet needs to recognize what the options are at this point. So when we think about an endodontic procedure like a traditional root canal, when is that appropriate for these younger dogs? Because I know I've always been told, and maybe there's some new information you have for us, that if the apex is not closed, we don't have apexification, that we cannot do a standard root canal therapy because any preparation we put in the teeth will just basically extrude out that open apex. So, what's new on that doing root canal therapy on immature teeth?

SPEAKER_00 47:40

Okay. So, what you would have to do is you would have to do an apexification procedure if the tooth is dead. So an apexification procedure would be where you fill up the tooth with calcium hydroxide, or you put MTA down in the apex and then you perform a root canal. Yeah, the the MTA would be a better option because it's not as many steps. With the calcium hydroxide, we used to have to replace it, and then if your apex wasn't formed, then replace it, and then repeat that until the apex was formed. With the MTA, you clean out the root canal, plush it really good, put the MTA down in the apex, and there's newer products that you could do it in one step. And so you put the MTA at the apex and then you do your root canal on top of that.

SPEAKER_01 48:36

Does this involve multiple anesthetic episodes to do this?

SPEAKER_00 48:41

Anywhere from one to two episodes because the uh the newer products set up more quickly than the original products. It used to be that it took four hours to set up. Oh wow. And so you want to keep a patient under right, right. So what you would do is you'd have them come back one to four days later, and then once it's set up, then you would go ahead and do your root canal. But they have newer products that you can maybe just do it all in one setting. So regenerative endodontics, where you put the MTA at the apex and then you cause bleeding, and then that bleeding can maybe cause new dentin potential to develop and then put your restorative at the end. But there's different things that can be done in a dead tooth, but it's somewhat more involved than if you get it when it's alive.

SPEAKER_01 49:41

Yeah, always better if we can get it when it's alive. And we know the success rate is really high for those vital pulp therapies if we can intervene quickly. But that's really exciting. I definitely am really wanting to learn more. We're going to host a webinar, you and I, on this topic. And you can then actually show people through a PowerPoint presentation and really get in depth on these techniques. So I'm really excited about that. That will be coming in the next couple of months here, where we'll sign people up for that. And then we'll have that course on demand as well on my website. So that'll be exciting to be able to learn more about some of this cutting edge medicine when it comes to getting a tooth to come back to life, which I thought was impossible. So I'm excited to hear about that. And just knowing that some of these techniques out there are being researched and perfected because it's so hard for us to catch these tooth fractures, especially when we're dealing with these young patients quickly enough and get the pet to the veterinary dentist quickly enough. There's just so many barriers to the stars aligning, as I mentioned, that if we have some other options, and especially if the client is motivated to save that tooth, what a great thing for the future of veterinary dentistry. Are there any specific patient that you remember from all of your experience doing these things that just really stood out where you had a really amazing success when it came to a tooth fracture on a young dog, getting that fracture treated, and then you know, that being successful? Or is there any patient that stands out in your mind over the years?

SPEAKER_00 51:17

So I think uh what comes to mind is not necessarily a dog, but it was a case of a polar bear at the uh Central Park Zoo. And I had never done a root canal on a polar bear, and I suggested they call Peter Emily and I would go and help Peter Emily, and I'd go to the Central Park Zoo and help do that procedure. And so what we did was we met, and the it was it's interesting because this particular polar bear, my husband used to work and travel through Central Park to come home, and he saw this polar bear and he was licking his lips. And he said, Oh, I wonder what's wrong with that polar bear. I said, That's a polar bear we're gonna do tomorrow. And he had these draining tracks underneath his chin. And uh, so I went over there with Peter Emily, and together we, the Zoo Vets, anesthetized him, and we were doing the root canal. We had to do two surgical root canals plus conventional because the canals were so long, and so we ended up doing a surgical root canal, both surgical root canal and a conventional, and then halfway through the procedure, I said, Who's moving the bear? And I thought somebody had pushed him. Well, he was starting to wake up. Well, there was a flurry of activity, and they were able to get him back down. We finished the root canal, and the bear did fine. So that was probably my most exciting story.

SPEAKER_01 52:55

Yes, that's exciting. And you know what an amazing thing for your husband to notice that this bear seemed to be having a problem because him being your husband, I don't know what he does for a living, but I'm sure you talked a lot about what you do over time and that he realized that he needed to be watching for these things and that something wasn't quite right with that. Yes, yes, that was fun. Yes, yeah, what a great story. I love it. And just the anesthesia part of it. I did another episode called Dentistry on the Wild Side with Loïc Le Gendre, and he also anesthetizes wild animals sometimes out in the wild, sometimes in zoos. And he had some interesting stories about some cases like that where we have to depend on our anesthetist to keep us safe while we're trying to do the tooth stuff. Yes. Yeah, how exciting. So, as we wrap up this episode, is there any specific big takeaway that you feel the listener should be aware of, given what we've talked about thus far?

SPEAKER_00 53:58

I would say the biggest takeaway is that be aware of young animals with tooth trauma or any kind of head trauma, because the likelihood is that they will have a tooth fracture. And that the sooner they can address the tooth fracture in a young dog, the better it is for the patient.

SPEAKER_01 54:22

Perfect. And our emergency veterinary friends out there, we talk about how important it is that they're there to save the patient's life in an emergency. And they may notice, especially if they are in the mouth of the patient, that the patient's had some tooth trauma. But I think our emergency veterinary friends should also be aware that tooth trauma is actually more urgent than it seems. If we get through the emergency of the airway, breathing, cardiac, all that stuff that we need to do to save animals, which I don't work in ER. It's a whole nother world over there. But they often really put much less importance on some of that dental trauma. I think this is a lesson for those veterinarians and teams. We really want to not ignore the tooth trauma that could have happened when a patient had some other sort of trauma, hit by a car or hit by like a golf club. We live in Arizona, so there's a lot of golfing around here. Baseball is big in Arizona too. So it's the perfect place for those two things to happen to a dog if they're not careful. Just knowing if they see and present in an emergency situation that the tooth trauma should be addressed as soon as possible with their regular veterinarian, or maybe just be referred directly to a veterinary dentist so that they can then do the right things for that patient, especially in those young patients. Because we learned today from Dr. Sandy that this is time sensitive. We don't want to wait because as soon as these teeth start to go down the path of pulbitis, we could get to pulpal necrosis and death of the tooth. And then our options become much more risky, time consuming, expensive for the client. And the failure rate for those things is probably a lot higher than it would be if we were able to do vital pulp therapy on a young tooth that has had trauma as soon as it's fractured within hours to days to maybe, as you said, we could go out as far as maybe three weeks, but we really have to find these things and get them taken care of. And the veterinary dentist may not be able to get the patient in as quickly either. So the sooner the better that we get this appointment started so that we can really help these patients. So thank you so much. And we'll have so much more in-depth information on the webinar that we'll offer for CE credit. So if you are interested in getting CE credit for a subject such as this, again, we're going to be putting on a webinar where Dr. Sandy will show a lot of in-depth information in a PowerPoint presentation so that we can learn more about these techniques. Before we leave today, this is the time you get to ask a question for my next guest. So, Dr. Sandy, did you happen to think about a question that you'd like to leave for the next guest of the Positive Veterinary Dentistry Podcast?

SPEAKER_00 57:02

Okay, so I think what I would like to ask is what is your favorite maxillofacial surgery to perform? And why is that your favorite procedure?

SPEAKER_01 57:16

Okay, perfect. Our next guest is an oral maxillofacial surgeon. So we're really excited to have Dr. Stephanie Goldschmidt answer that question. So thank you so much for that question. That's perfect. Thank you all to the listeners for joining us today on the Positive Veterinary Dentistry Podcast. If you found this episode helpful, be sure to share it with your friends because we're trying to get more people to know about this podcast so that we can spread the word about veterinary dentistry and these really relevant subjects. So share it, like it, and pass it on. What you do in dentistry truly matters for the health, comfort, and quality of life for the animal patients that we take care of. So thank you for listening to the Positive Veterinary Dentistry Podcast, and we'll see you next time.