How to spot signs of oral pain in your pet patientsSince pets can’t talk about their toothaches, it’s up to us veterinarians to know what to look for February 13, 2017 By John Lewis, VMD, FAVD, Dipl. AVDCFigure 1: Fractured tooth 304 shows evidence of pulp exposure in a 1 1/2-year-old male German shepherd who was not releasing from the bite sleeve prematurely. There’s no ache like a toothache. I’ve had a few toothaches in my short life, some due to my affinity for sweets and some due to my affinity for baseball. The only pain that I know of that rivals dental pain is back pain. Nociception of the teeth is provided by A-delta nerve fibers within the pulp, capable of creating sharp pain associated with a sudden insult to the pulp. C fibers are responsible for throbbing pain of a chronically affected tooth. The inherent challenges for veterinarians providing dental care to animals are: Animals won’t tell you which tooth or which area of the mouth hurts. Pets suffering oral pain don’t show many outward signs, so convincing owners that their pet requires treatment may be difficult. Watch for Signs In the vast majority of cases, animals do not let a painful mouth stop them from eating or performing their expected duties. Careful observation may provide clues for the astute observer. History may reveal a patient that goes to the food bowl and thinks about eating but turns away at the last minute. However, turning away from the food bowl is the exception. Although this can occur with dental disease, disease further down in the digestive tract may result in turning away from the food bowl. Patients with oral pain may show signs of slow, deliberate chewing, preferentially chewing on one side or swallowing food whole without chewing. Preferential chewing may cause asymmetric accumulation of plaque and calculus, with more buildup on the painful side due to a lack of self-cleansing. Cats may become selective with their food, preferring canned food to dry food. Cats also may become more reclusive or sedentary. Similarly, dogs may become sedentary, which owners may attribute to “old age.” However, the most common sign of dental pain is no outward sign at all. During the conscious examination, pets may provide insight into whether they have oral pain. If a pet is not reluctant to have you listen to its heart but is very reluctant to have you look in the mouth, this may be an indicator of oral pain. Pain can be associated with an individual tooth in the case of endodontic disease, such as a fractured tooth, or it may be generalized throughout the mouth in cases of stomatitis. Is periodontal disease painful? Humans tell us no, but, as veterinarians, we commonly see a severity of periodontal disease that is rare in human dentistry. Marked root exposure, tooth mobility and progression from periodontal disease to involvement of the endodontic system can cause significant discomfort. It’s not until after a patient receives appropriate dental treatment that owners and clinicians notice a difference in the patient. If I had a nickel for every instance where an owner told me her elderly dog was “like a puppy again” after extractions due to severe periodontal disease, I would have at least $20! Bite Blues An example of a canine patient who showed subtle signs while tolerating dental pain was Legend, a 1½-year-old German shepherd, who had been performing bite work on a bite sleeve. Legend’s owner noticed that he was not holding onto the sleeve with as much fervor as before. He would let go prematurely. It was noted that the left mandibular canine tooth was fractured with pulp exposure, and Legend was presented to me to determine whether the condition could affect his bite work (Figure 1). Having seen this problem with multiple police dogs, I thought the fractured tooth could be the entire reason for Legend’s decreased enthusiasm. We placed Legend under anesthesia. Dental radiographs showed periapical bone loss and a wider canal of this tooth compared to the contralateral canine tooth. The root apex appeared closed and amenable to orthograde root canal therapy. A large, necrotic pulp was removed (Figure 2), and the canal was cleaned with a combination of sterile lactated Ringers’ and sodium hypochlorite. Rotary files were coated in a paste containing urea peroxide, propylene glycol and EDTA. After cleaning and drying the canal, it was filled with an inert material to minimize the likelihood of percolation of bacteria into periapical areas. Composite restorations were placed at the fracture and access sites, a crown preparation was done, and a detailed impression was obtained to allow for fabrication of a metal crown. A temporary composite crown was placed over the tooth to protect the crown prep margin. After the dental laboratory returned the metal crown, Legend was placed under anesthesia so the crown could be permanently cemented in place (Figure 3). Figure 2: Extirpated pulp from tooth 304 is grey-brown in color, suggesting necrosis. Even if the A-delta fibers and C fibers within the pulp are no longer transmitting pain, inflammation in the periapical area the tooth and surrounding bone can result in pain. Figure 3: A full metal jacket crown was cemented on tooth 304 after root canal therapy. Since having tooth 304 treated, his bite work has improved, suggesting the tooth may have been the cause of his bite blues. It’s Inevitable Did Legend ever miss a meal? No. Did he cry out in pain when engaging the bite sleeve before having tooth 304 treated? No. Did he tell us which tooth was causing a problem on conscious examination? No. This is one of many cases that show how veterinarians must be on watch for oral pain in our patients. You may not have seen a pet with oral pain this week, but the question is, has one seen you? If you have similar stories, consider submitting them to www.HelpStopPetDentalPain.com. The website was envisioned and funded by the late Patricia Frost Fitch, DVM, Dipl. AVDC, who spent much of her life raising awareness of the transformative nature of appropriate dental care. Please take a moment to share your most memorable dental story in her honor. Dr. John Lewis practices veterinary dentistry and oral surgery at NorthStar Vets in Robbinsville, N.J. Originally published in the January 2017 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!