Category: Dogs

Laser Surgery

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We have been using the carbon dioxide laser at the Long Beach Animal Hospital for over 20 years.  We are one of only a handful of animal hospitals in California that have this capability. It is a highly advanced and technical piece of equipment that we never dreamed about having while we were training to be veterinarians. Its one of the ways we offer state-of-the-art care at Long Beach Animal Hospital.

The laser is a high precision instrument 

It is carefully calibrated for each individual surgery

This video shows how we set up one for a dog neuter, and how the laser checks its circuits and calibrates itself.

You get to wear these cool glasses when the laser is on

Dr.P has taught many surgeons how to use the laser. Here he is teaching one of our externs.

GPig-EyeSx-11

Dr. Ridgeway is using the laser on a guinea pig for eye surgery.  He is using magnifying glasses due to the small size of his patient. Small patients cannot tolerate blood loss, so the laser has been a tremendous tool for surgery in animals that only have a few drops of blood in them to begin with.

Laser-Tortoise

Here he is teaching one of our externs on the use of laser in a tortoise. Veterinary students do not get exposed to the laser routinely while in veterinary school, which is one of the reasons they do an externship at our hospital. Our goal is to impart all of our knowledge to them as they start their careers.

Laser Theory

A carbon dioxide laser emits a high energy beam of infrared (invisible to the human eye) radiation in the form of light waves that has many veterinary applications. If you would like to learn more about the mechanics of lasers in general, including safety procedures, how they work, and why we use the carbon dioxide laser as opposed to other lasers, click here.

Graphic photos on this page.

Advantages

There are several advantages to the COlaser surgery:

  1. Pain Reduction

    Your pet will experience significantly less post operative pain in almost every instance. As a matter of fact, the pain reduction is so great that we perform declaws on cats only with a laser beam. This reduction in pain is a result of the unique characteristics of the laser beam as it cuts nerve endings, preventing the raw ends that are characteristic of scalpel blades.

  2. Swelling Reduction

    Whenever an incision is made in tissue with either a scalpel blade or scissors, inflammation is started in the affected tissue. This inflammation is a result of interaction with the circulatory and lymphatic systems. Because the laser beam effectively cauterizes the lymphatic system, there is much less post operative swelling. This makes your pet much more comfortable while it is convalescing from surgery.

  3. Control of Infection

    The laser beam operates at a temperature of over 200 degrees Fahrenheit. This makes it highly effective at killing bacteria that have the potential to cause an infection. This is particularly important in areas where it is difficult to prevent bacteria from contaminating the surgical site. Examples include abscesses and cat declaws.

  4. Minimal Surgical Bleeding

    When an incision is made with a scalpel blade, small blood vessels are cut in the skin and the layer of tissue just under the skin. These blood vessels can ooze throughout the surgery and even postoperatively. Traditionally they are taken care of by clamping them with hemostats, cauterizing, or holding gauze sponges on them until they stop. All of these procedures take time, which means the surgery takes longer and there is more post operative swelling. The laser beam is a highly effective coagulator of small blood vessels. Less bleeding during surgery means less anesthetic time and faster recovery time.

    Even though lasers are used effectively in many surgical procedures they are not used in every surgery. They are especially useful in oral surgery, neuters, growth removals, and amputations of small extremities. We also use it in small animals, especially birds, because of the laser’s great effectiveness at minimizing bleeding.

    The following sections give specific examples of the use of the carbon dioxide laser in our hospital.

    Neuter

    The laser is particularly advantageous in this surgery. Prior to using the laser we used a scalpel blade to make the scrotal incision and throughout the whole procedure. When using the scalpel like this, the scrotum would swell over several days post operatively as small blood vessels oozed. This was obviously very uncomfortable in such a sensitive area. The laser has eliminated this completely.

    Canine-neuter6

The laser is being use to cut through the outer layer of the testicle, called the tunica vaginalis

Canine-neuter7

The testicle is exposed, along with the epididymis and blood supply. Notice the lack of bleeding.

We neuter a wide variety of animal:

Cats

Rabbits

Dogs

Rats

Bladder Surgery

Bladder stones are not uncommon in animals. The bladder is usually inflamed and highly vascular, causing significant bleeding when we incise the bladder to remove a stone. The laser has revolutionized this surgery. This is a very sensitive internal organ, and anytime we can make an incision in such an organ without any bleeding, the healing period is much faster and less painful.

Surgery-CatLaserBladder

Here is the initial incision in a cat with no bleeding from the bladder

Laser-cystotomystone

This is a dog with the stone being removed from the bladder after the laser incision

Our bladder stone page has much more detail, including a movie of removing bladder stones from a dog. We also have pages that show removal of bladder stones in Iguanas and tortoises (you don’t want to miss this tortoise bladder stone page)!

Feline Mammary Tumor

These tend to be malignant and highly vascular, causing substantial time during surgery controlling bleeding, along with considerable bruising after surgery. The laser has revolutionized this surgery.

In the video note how diseased the subcutaneous tissue looks and the total lack of bleeding in this highly vascular area. Also notice as milk is excreted from the gland as the surgery progresses

Our web site has a detailed page on mammary tumors in animals.

Rat Mammary Tumor

Rats get a mammary tumor under the skin very commonly. The laser is huge when it comes to removing them with minimal bleeding, which is important in a small animal.

Surgery-RatMammary-3

Surgery-RatMammary-4

Click here to see the full surgery

Oral Tumor

A tumor that can be encountered in dogs and cats is called sqamous cell carcinoma. These pictures are of a dog that had one on its left jaw, called the mandible. The only way to completely cure this tumor is to remove the jaw on that side, a surgery called a hemimandibulectomy. In this case the owner decided against it, and will have the growth removed as much as possible with the laser, following up with radiation therapy.

The tumor is identified by the white arrow. It had been removed 1 year earlier, but as expected with this type of tumor, has recurred. This time the surgery will be with the laser for maximum comfort for Jackey.

The post operative appearance immediately after it has been removed by the laser. Minimal bleeding and swelling are apparent.

We were able to suture gum tissue over the defect left by the surgery. It is hard to tell in this picture that any surgery was performed at all.

This tumor is in a Tegu

LaserSurgery-IggieJaw

The arrow points to the tumor

LaserSurgery-IggieJaw-2

No sutures, no bleeding, no pain, and no inflammation

Declaws

This is a request from people that want to keep their cats indoors. Prior to a declaw, we advise keeping the nails trimmed short or the administration of Soft Paws on the nails, along with a scratching post. One of our nurses will gladly give you a demonstration of these options.

We prefer you use other options before thinking about laser declaw, and will show you how to gently trim the nails

If this does not work you need to make an appointment to have your cat examined by one of our doctors and determine if it is a candidate for the surgery. We do not do this surgery routinely.

Prior to the introduction of the carbon dioxide laser all declaws were done with a scalpel blade. It is a very precise surgical procedure that our doctors have performed thousands of times. Unfortunately, the post operative period was painful, the feet were bandaged, and most cats had to stay in the hospital for several days. On older cats this surgery was even harder on the pet.

The advent of declaws with the laser surgery has substantially minimized these drawbacks. There is usually no bleeding during the surgery so a tourniquet is no longer used. Most of them can even go home the day of surgery but we prefer to keep them for observation for 1-2 days. Most cats have so little pain or discomfort they are jumping and running before nature has had time to complete the healing process. Always restrict their activity at home for the first few days to prevent this problem.

This cat’s nails have grown into its pads due to the owner’s inability to care for it properly. This is a painful situation and makes him a candidate for a front declaw.

Feline-NecroticNail

Sometimes the problem is even more severe, and the severely infected toe (on the right) needs amputation. This is where the laser shines.

The following pictures are from an actual declaw that we performed at our hospital.

Surgery-CatLaserDeclaw

The nail is gently pulled forward prior to surgery to open up the area behind the nail where the incision with the laser will be. Bone is not cut during the procedure at any time, only tendons and ligaments are cut.

Surgery-CatLaserDeclaw-4

The laser beam (it is invisible to the naked eye) has started the incision at the top of the toe. It will cut through skin and tendons along with ligaments in between the digits.  The nail, with its attached bone (called phalanx 3), is removed.

The surgery is complete with no bleeding, swelling,  or trauma to any bone. The top arrow in this picture points to the bone at the joint of the 2nd knuckle. The bottom arrow points to the intact pad that has not been touched either. A drop of surgical tissue glue will be put on the pad to cover the end of the bone.

The foot immediately after surgery. There is no need for a bandage.

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Fluid Therapy

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Fluid therapy might just be the most important medical therapy we perform on sick animals. Dehydrated pets feel ill, cannot fight disease, do not eat well, and cannot metabolize drugs efficiently. Dehydration decreases the circulation to two very important organs, the liver and the kidney. These organs are then unable to perform vital functions, some of which include detoxifying drugs and removing waste products.

We give fluids to a wide variety of species in addition to dogs and cats. They can be ill, and need fluids for many different reasons.

This guinea pig being examined by one of our externs has a problem with overgrown teeth and cannot eat well. This has caused him to become dehydrated, and in need of supplemental fluids.

Before coming in for treatment this rabbit was painful from a broken leg and not eating well, so it became dehydrated. Supplemental fluids to correct the dehydration, and a splint to take away the bone pain and allow the healing, were needed to get him back to being a normal bunny again. You can see how we treated his fracture here

Yup, we even give fluids to 120 pythons when they are ill or dehydrated. This is probably not something you want to try at home!

Fun Facts

Before we get started on the specifics, lets go over a little background on fluids.

The body weight of a normal dog or cat is about 60% water, puppies and kittens are up to 80% water. These numbers show the importance of a proper fluid balance for normal physiology, especially in puppies and kittens when these animals become dehydrated.

The fluid in the bodies of normal animals resides in 3 areas:

Inside the cells of an individual organ, called the intracellular space. 65% of the total fluid in the body resides in this intracellular space.

In the bloodstream, called the intravascular space. 25% of the total fluid in the body resides in bloodstream.

In the tissue surround the cells, called the interstitial space. 10% of the total fluid in the body resides in the interstitial space.

When the intravascular fluid is low hypovolemia results. Hypovolemia means the body cannot deliver adequate oxygen to the cells, and a pet can go into shock. If not treated death can ensue. We assess this low oxygen problem with an instrument called a Pulse Oximeter, which measures the oxygen saturation of the hemoglobin molecule in the red blood cells. It should be in the 90 percent range.

This pot-bellied pig, with a 92 % oxygen saturation, and a heart rate of 82 beats per minute, is normal

Pets with hypovolemia are very ill and can exhibit some of the follow symptoms:

Elevated heart rate, called tachycardia.

Slow heart rate, called bradycardia. This occurs when your pet is in the act of dying.

Weak peripheral pulses. We detect this on an exam by palpating the femoral pulses while simultaneously listening to the heart.

Prolonged capillary refill time (CRT). For a normal animal this should be under 2 seconds.

This is how we check the CRT. This pet is under anesthesia, a time when we carefully monitor this parameter

Cold extremities

Low blood pressure (hypotension).

Hypothermia (low body temperature)

When the interstitial fluid is low dehydration results. This is not usually life threatening until the dehydration progresses to around 10%, which now causes hypovolemia. Dehydration is detected during an exam when any of the following occurs:

Tacky or dry mucous membranes (the gums)

Skin tenting

Sunken eyes

Elevated BUN or Creatinine on a blood panel

Elevated hematocrit and total protein

blood sample will also give clues to dehydration, especially the total protein level and the hematocrit.

This is the hematocrit test, checking the percentage of red blood cells in the serum, giving us information on the state of your pet’s hydration

After the hematocrit is measured we break the tube in the middle and place the serum on an instrument called a refractometer to check the protein level. In conjunction with the history, exam findings, and hematocrit level, the protein level helps us determine the degree of dehydration.

Hypovolemia and dehydration can occur independently. A dehydrated patient might not be hypovolemic, and a hypovolemic patient might not be dehydrated.

Our doctors decide on how much fluid to give your ill pet based on the following:

The normal (called maintenance) amount of fluid your pet needs every 24 hours to maintain normal physiology (called homeostasis).

For a dog this is 60 ml for each kg of body weight. For a 20 pound dog this is 545 ml (1/2 of a liter, or 30 ounces) per 24 hours.

For a cat this is 45 ml for each kg of body weight. For a 10 pound cat this is 204 ml (0.2 liters or 7 ounces) per 24 hours.

The degree of dehydration of your pet

A 20 pound pet that is 7% dehydrated needs 600ml to correct this dehydration. This is more than pet owners realize, and why proper fluid therapy is so important when we hospitalize your pet.

Ongoing fluid losses like vomiting or diarrhea. As pet that has been burned has tremendous fluid losses due to seepage of serum at the burned skin area. This ongoing loss is subjective, but it needs to be added to the calculation above if your pet continues to have these fluid losses.

Symptoms of Dehydration

Signs of dehydration include lethargy, anorexia (poor appetite), sunken eyes, sticky gums, constipation, and a general feeling of malaise. It is diagnosed based on a history of anorexia, vomiting, diarrhea, or extra fluid loss, in combination with a physical exam and diagnostic tests. During an exam a dehydrated pet will shows signs of dehydration when the problem is greater than 5 %. The page talks about the two primary methods used to give fluids to pets. The first is intravenous, and is performed only by us in the hospital. This is not a treatment method you will do at home.

Types of Fluids

The type of fluids we will be describing are called crystalloids. This are the kinds most people are used to, and are usually lactated ringers solution (LRS) or sodium chloride (NaCL), and variations thereof that we might use in specific situations.

These are some of the ingredients in LRS

Another type of fluid is called a colloid (hetastarch or hydroxyethyl starch). Colloids are used only in specific situations, which are not common. For the remainder of this page we will be referring to crystalloids.

Intravenous (IV) Fluids

I.V. (intravenous) catheters are used extensively in pets that are sick or those pets that are about to be anesthetized. These catheters allow us to administer medication directly into the venous system for rapid distribution to the whole body. Medication given this way acts faster and is more controllable, a significant advantage for an ill pet or in an emergency. IV administration of fluids is critical in pets that are hypovolemic.

Intravenous fluids are important during surgery. We monitor this closely in many ways, especially with the blood pressure.

If your pet is ill and staying in the hospital, or about to undergo anesthesia for any reason, an I.V. catheter to allow fluid administration is one of the most important therapies we can institute, and can literally be life saving.

This dog getting his teeth cleaned was put on IV fluids before the procedure to stabilize the kidneys for the anesthesia. The fluids are continued for the duration of the procedure, and will be administered until this pet is fully awake and its owner is picking it up.  

The placement of the catheter requires technical skill and knowledge, particularly in small or dehydrated pets (the veins in these pets are small and damage easily). Improper placement of the catheter can literally cause more harm than good. Our nurses excel at placing I.V. catheters in all species.

Because the catheter is introduced directly into the venous system, it must be placed in an aseptic (sterile) manner. The hair over the vein is shaved, and special tape is placed over the catheter. 

Comfort is also important when placing the catheter due to the small nature of some of our patients, and the duration the catheter must stay in the vein. This tape and catheter is constantly monitored by our staff for comfort and sterility. After 3-5 days we usually replace the catheter in order to minimize the chance of the catheter causing an infection. 

I.V. catheters are usually placed in one of three veins:

Cephalic Vein-This is by far the most common vein to use. It runs along the top of the foreleg of dogs and cats. The illustration below shows the placement of this catheter in a large dog.

Jugular vein-This vein is in the neck. A catheter placed in this vein allows longer term use and the ability to give larger volumes of medication with different viscosity’s.

Saphenous-This vein is on one of the back legs. It is mostly used when the cephalic vein is unusable, but can be used at any time.

Various other veins are sometimes used, by they are reserved for some of the more unusual species of animals we deal with. In some of these pets like birds, that have minuscule seized veins, we cannot give the necessary emergency fluids intravenously. In these cases we use what is called an intraosseous catheter. This catheter goes directly into the bone marrow, and allows us to give the necessary fluids to a small creature rapidly and effectively. In birds it is put in what is called the tibia tarsal (tiboitarsus) bone. This is equivalent to our tibia or shinbone. It is put in at the knee joint.

This radiograph shows the placement of an intraosseous catheter. It is going down the shaft of the tibiotarsal bone in this bird that came in collapsed and in shock. The bird responded and recovered completely after we administered fluids through this catheter. 

Your pet’s catheter will stay in for the duration of its hospitalization or procedure, and will not be removed until you return to pick up your pet. Your pet may go home with a small piece of tape and cotton where the catheter was. It can be removed several hours later after you return home.

We use many different types of fluids, the most common one being Lactated Ringer’s Solution. The amount of fluids given are calculated and  monitored carefully.  We use a special fluid pump that gives a consistent amount of a period of time.

Each patient receiving fluids has a custom fluid chart outside its cage for close and constant monitoring of the fluids. Our doctors make adjustments in the type and amount of fluids as diagnostic tests like blood panels, and your pet’s response to treatment, are analyzed. 

Subcutaneous (SQ) Fluids

The second method used to administer fluids is subcutaneously (under the skin) between the shoulder blades. The administered fluid slowly absorbs over several hours. In this hospital and on an out-patient basis, this method is used for pets that are not seriously ill, but just need some additional fluids to maintain hydration, fight a fever, or stimulate the appetite.

If your pet needs to be on SQ fluids on a long term basis due to a chronic disease, think of it as bonding time and make it a positive experience

This section on SQ fluids contains  detailed step-by-step descriptions on how to give fluids at home on an ill pet, an older pet, or a pet with kidney disease. When you first read it you might think there is no way I can do all of that. Once you observe us do it in front of you, and then do it yourself, you will realize it is not anywhere is difficult as you think when you read about it the first time.

This video is how we give sq fluids at our hospital. Notice how calm this dog is.

SQ fluids are of special benefit for pets that need long term fluid administration at home, usually older (geriatric) cats or those with kidney disease. This is the animal version of dialysis in people, and it works extremely well. These fluids at home are highly beneficial, and have had cats with chronic kidney disease do well for years with this treatment at home.

If your doctor feels your pet needs SQ fluids at home you will be taught how to administer them by our nursing staff. At first it might seem an impossible notion to give your pet fluids at home. Not only is there the psychological fear of using a needle, or worry about hurting your pet, there is also a worry that your pet will not stay cooperative long enough for the few minutes it takes to give the fluids.

Rest assured that you will not be forced into giving these fluids if you feel uncomfortable, although we have yet to encounter a client that was not able to perform this procedure at home. This is because we have extensive experience in this area, and we teach you at your own individual pace. Only when you feel you are ready will you proceed on your own.

You will be given as many personal demonstrations as necessary, and can return to the hospital at any time for further demonstrations or to make sure you are performing the procedure properly. You are welcome to bring your pet in at any time for assistance in giving the fluids, so do not feel you are on your own. If you are out of town, your house sitter can bring your pet in for these fluids. We consider you part of our nursing team and are willing to give any assistance needed. Before you are given a live demonstration the following basics will help prepare you.

The scariest part of the whole procedure for most people is the actual insertion of the needle into the skin so that the fluids flow under the skin (SQ). You will watch us do this as many times as you need to overcome any fear you might have. When you realize it is not all that difficult by watching us do it, we will hold your hands when it is your turn if needed.

Practicing by inserting a needle into an orange or similar fruit can be helpful. Different sized needles, ranging from 22 gauge to 18 gauge, are used to give SQ fluids. During the demonstration we will show you which one works best for your pet.

The 18 gauge needle, at the top, has the largest diameter. Fluids flow fast through this needle, taking less time to give them. If this size needle is uncomfortable for your pet, we will try the 20 gauge next because it is smaller, although the fluids will flow more slowly. On small pets we might even use the 22 gauge needle. 

During this demonstration you will be told exactly how much fluids to give. For most cats with chronic kidney disease, this is 100ml once or twice daily. The fluid bag has 1000ml (1 liter), so for the average cat you will be able to give these fluids for ten days. This might vary depending on many factors, and your doctor will determine the amount and frequency. Do not change this unless instructed to.

Keep children and other pets away if they are disruptive during the process of giving the SQ fluids at home. Have all of your equipment readily available, usually on the same table as your pet. Depending on the size of your pet, the table should be around waist to chest high. It is helpful to set up one area of your house to give the fluids. Hang the fluid bottle in this room for easy access. It should be at least a few feet above the table for optimum flow. You will be shown how to set this up by one of our staff.

Store the fluid bag at room temperature and cover the bag so no light hits it. We sometimes add medications like vitamins and electrolytes to the bag, and light can affect them.

When you purchase a fluid bag from us it needs to be set up with the IV line. We will show you how to do this in person. You only need to set it up when you purchase a new bag. After that, you give the fluids with a new needle each time, keeping the IV set attached, until the bag is empty.

Never use the needles more than once since they are sterile and very sharp when first opened. Repeated use could cause an infection in your pet, and makes the needles dull, causing discomfort on administration. Needles are inexpensive, so don’t take the chance by re-using them.

When you purchase the bag it comes wrapped in a plastic wrapping. Remove the wrapping at home when you are ready to set it up to give fluids to your pet. After you remove the outer wrapping lay the bag on your table or hang it from a coat hanger. 

Open the sterile IV set and lay it on the table


These are the components of the IV set

The large white end with clear receptacle goes into the fluid bag once the white cap is removed. The clear container above will be filled part way with fluid once attached. 

 At the opposite end of the IV line is a small blue cap. You remove this blue cap when you attach a needle, which you will learn about later. 

The large blue plastic piece in the center allows you to turn the flow on and off, and also adjusts the rate of flow. Make sure the white wheel is in the off position like this when first setting it up. 


Remove the white plug from the bottom of the bag. The cap is in solidly, so you will need to pull hard to remove it.

 You can do this while the bag is hanging, or while it is laying on the table. Discard the white cap, it will not be used again. 

Remove the white cover from the IV set receptacle. It is sterile, so do not touch it to anything at this point. 

Hold the hanging bag steady, or lay it flat while doing this, so you can put it straight in without touching anything else. 

Insert it all of the way into the fluid bag 

Hang the bag, then squeeze the receptacle until the fluid fills half of the receptacle

It should look like this when you are done

Lay the needle next to the end of the IV set that has the blue cap

Remove the clear plastic at the base of the needle by twisting it either direction. The open base of this needle is sterile, so do not touch it to anything until you insert it into the IV line. 

Remove the blue cover at the end of the IV set. Turn the fluids on and let a few seconds of fluids flow through the IV line to remove the air. Let these few drops flow into a small bowel or on to a towel. Do not touch the end of this line to anything. 

A few air bubbles left inside the IV line will not cause any problems 

Insert the needle straight into the opening. Hold you left hand still as you twist clockwise with your right hand to lock it tight

Hang the IV set over the fluid bag. You are now set to give the fluids. 

Every pet reacts differently to the actual giving of the fluids, and they feed off of your emotions, so cool and calm usually works best. If either one of your gets worked up, stop and try again later.

Make sure the location to give the fluids is subdued and calm, with no excessive lighting or noise to alarm your pet. Take your time by bringing your pet to the table and interacting with it by petting it and holding it. You can even feed it while giving the fluids. A towel for restraint, or another person holding the head, might even be appropriate.

Hold your pet to the side, make a small tent of the skin between the shoulder blades, remove the cap over the needle, and rapidly insert the needle between the shoulder blades in one motion.

Insert it all of the way in until the hub touches the skin. Turn on the fluids completely on by moving the white wheel all the way to the top, and give the prescribed amount of fluids. For most pets, this takes only a few minutes of your time daily, a few minutes of your time that will be highly advantageous to your pet. 

When you are finished giving the fluids remove the needle from your pet and cap it. Remove the used needle and place a new sterile needle at the end of the IV set, and hang the IV set over the bag as before. You are now ready to give the fluids again the next time one of our doctors prescribes.

Finally, pat yourself on the back for a job well done, have a seat, and breathe deeply (or get a stiff drink if needed to calm your shaking hands).

Place all used needles in a safe place with no access to children or pets. A sharps container to hold these needles is the best place to put them until disposal. Dispose them according to the guidelines in your community. Here are some local disposal centers for needles. If you are not near one of these areas call us at 562-434-9966 for other locations:

EDCO Recycling and Transfer Center

2755 California Ave.

Signal Hill, CA 90755

562-597-0608

L.A. County Sheriff- Lakewood Station

5130 N. Clarke Ave.

Lakewood, CA 90712

Huntington Beach Collection Center

17121 Nichols Lane

Huntington Beach, CA 92647

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Gall Bladder Removal in a Dog

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Surgical removal of the gall bladder is called cholecystectomy. Most of us have heard of gall bladder surgery in people. It is not as common a surgery in animals. This page has pictures of a surgery to remove the gall bladder in a dog. At the end of this page you can see what gall stones look like.

Graphic surgical pictures on this page.

Our patient is an 11 year old Silky Terrier that came to us with some significant symptoms. They included anorexia for several days and lethargy. Her initial blood panel showed high elevations in Alk Phos., AST, and bilirubin.

Her blood panel is typical of a dog with this problem. You can see the significant elevations in her liver enzymes and bilirubin. Even the electrolytes are abnormal.

Her urinalysis showed significant amounts of bilirubin 

We could see hepatomegaly on her radiograph. Initial treatment consisted of antibiotics, fluids, vitamin supplements, and I/D food. Heather rapidly got better on the treatment.

This is what the liver looks like on an abdominal radiograph

She had a recurrence of the problem 3 weeks later. At that time an ultrasound was performed and it was determined that she had a  problem with her gall bladder.

Her gall bladder, the dark area on the top left had a problem. The line in the center is measuring the size of her common bile duct, which is large in her case. 

This is her ultrasound report

She responded well to treatment with antibiotics and actigoll. When her enzyme test were almost back to the normal range we removed her gall bladder.

Before we do any surgery on the liver we make sure the clotting system of the body is working well. The liver is intimately involved with the bodies clotting mechanism, and we need to make sure we are not going to encounter a severe bleeding problem during and after surgery. This test is making sure her red blood cells are adequate (no anemia is present), along with the 4 clotting tests on the bottom, starting with Prothrombin Time. 

Our patient is now ready for gall bladder removal This is a specialized surgery that is tedious and requires an experienced surgeon. In Heather’s case we called in Dr. Linda Larsen, a specialist in surgery.

Dr. Larsen is a board certified surgeon, and experienced at this surgery

Monitoring of anesthesia is critical in an older pet with liver disease. Monitoring Heather’s blood pressure is an important aspect of anesthesia.

Surgery-Monitor

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

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Once our surgeon has scrubbed up and is  in sterile gown, gloves, and mask, the surgery begins

The incision into the abdomen is made at a special location called the linea alba. It is here that the tendons of the stomach muscles come together, and will hold the sutures after we close the abdomen.

The swollen liver is apparent as soon as she enters the abdomen

The first thing our surgeon does is locate the gall bladder

Now the careful dissection of the gall bladder starts so it can be removed

After careful dissection it almost full exposed at this point

As dissection of the gall bladder continued she traced it down to the common bile duct. The arrow points to the gall bladder under our surgeon’s finger. The vertical bluish structure below the gall bladder is the enlarged common bile duct.

The bile that is stored in the gall bladder is removed with a suction apparatus. This allows better visualization.

When she is satisfied with the exposure she puts several very strong sutures where the gall bladder attaches to the liver

Here is the trouble maker after it has been removed


A biopsy is taken of the liver to give us substantial information as to its health

The abdomen is flushed many times to remove any contaminants 

The long incision in the linea alba is sutured. After this layer, there are several more layers of sutures placed in the subcutaneous tissue and the skin.

At this point our patient is given a local anesthetic on the suture line, an additional pain injection, and the skin incision is treated with companion laser to decrease swelling and aid in healing,. You can its use on the video below.

Gall Stones

This is a different gall bladder removed from a different patient. This gall bladder was thickened due to stones in it.

The inside of the gall bladder after removal. The chronic thickening is apparent.

These are the gall stones that were found inside of it

The pathology report on this gall bladder

This is the analysis of these stones

Return to the Canine Diseases Page.

 

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Liver (PSS) Shunt Surgery

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A problem can occur where the blood flowing to and through the liver has a problem. There are several variations on this problem blood flow. In this page we will be correcting the blood flowing from a blood vessel that is directing the blood away from the liver and not into the liver like it should. This is called a liver shunt, also known as a porto systemic shunt (PSS).

This page shows a surgery to correct an extra-hepatic PSS (porto systemic shunt) in a cat using an ameroid ring. More than one year after surgery this cat is doing fine, so the surgery was a major success. The same procedure would be used in a dog, a species that gets this problem much more often than a cat.

Once our diagnosis was confirmed we put our little friend on medication to minimize the symptoms and make him a much better candidate for surgery. You can learn all about how we diagnosed and treated this problem before surgery on our Liver Diseases Page.

Graphic surgery photos on this page.

Dr. Adam Gassel of the Southern California Veterinary Specialty Hospital performed the surgery. This surgery is not performed by any veterinary surgeon. Dr. Gassel has the special training, expertise, and experience to perform this delicate procedure.

Aftercare is just as important as surgery in correcting this problem surgically, so this surgery needs to be performed at a 24 hour veterinary hospital where the staff is trained in this care.

A special constricting device called the Ameroid Ring is used to occlude the problem blood vessel to the liver

The ameroid ring is made of casein (a type of protein) that is surrounded by a ring of stainless steel. Over 4-5 weeks the normal fluid in the abdomen causes the casein to swell. Since it is encased in metal, the swelling slowly occludes the blood vessel with abnormal blood flow to the liver.

It is important that the casein swells slowly to allow the liver to adjust to the new pressure within it from the other blood vessels that are now increasing their blood flow to the liver. If the problem blood vessel decreases its flow to the liver too fast there can be serious consequences and even liver failure.

This surgery is performed after a careful review of all data and a discussion with the owner of the possible complications due to surgery. Cats tend to have more post operative complications compared to dogs, so special care is paid to their needs to help ensure a successful surgery.

PSS Surgery

Dr. P watched the surgery and took these photos to help explain this procedure.

Our friend is carefully prepared for surgery to minimize any chance of infection

While our patient is prepped Dr. Gassel is preparing his instruments


Our surgeon preparing to start the surgery while his anesthetist closely monitors our patient

The procedure does not start until our patient is under the proper plane of anesthesia and is stable

Our patient’s blood pressure is manually monitored throughout the procedure

Before making the initial skin incision Dr. Gassel confirms with his anesthetist that our patient is ready for surgery

The skin is incised gently to minimize trauma that could post operative discomfort and can delay healing

Small blood vessels are cauterized before proceeding further

The abdomen is entered at a special location in the muscle called the linea alba. This is where two tendons of the abdominal muscles come together. This area is stronger than muscle tissue, and will hold the final sutures when we put the muscle back together at the end of the procedure. This will prevent a hernia. 

As soon as the abdomen is entered the swollen and yellow discolored liver appears. You can see it between our surgeon’s fingers. The liver is this way because of the disease process going on. 

Finding and exposing the extra hepatic blood vessel for correction amidst all of the blood vessels, fat, and tissue in the area is tedious, and takes delicate dissection to get the vessel completely exposed for the Ameroid Ring to be placed. This is where Dr. Gassel’s expertise comes into play.

After much dissection you can see him starting to expose the vessel with his instrument. The extra hepatic blood vessel is the reddish horizontal object under the swollen and yellow-colored liver.

You can easily visualize the extra hepatic blood vessel over the hemostat as it is exposed carefully enough to put on the ring

The next important part of the procedure is picking the correct sized Ameroid Ring. If it is too big it won’t occlude the extra-hepatic vessel enough to help. If it is too small it will occlude the blood flow too rapidly and cause the liver to fail. 

The ring is prepared by removing the locking pin

The extra hepatic blood vessel is very gently placed in the ring through the opening in the ring where the pin was

When Dr. Gassel feels the ring is the correct size the locking pin is placed back in

The final appearance of the Ameroid Ring before our patient’s linea alba and skin are sutured back and our patient is awakened

Dr. Gassel and his surgical assistant after a successful surgery

One of the ways we diagnose a PSS is with a bile acids test. After surgery the bile acids test should be back to normal. We are happy to say that after over one year our patient’s bile acids test is back to normal and he is feeling great!

This was the original bile acids test on this cat. It should be less than 13, and is over 135. To have it go from this, to perfectly normal, is a testimonial to the expertise of the surgical team at the Southern California Veterinary Specialty Hospital.

There is much more to liver shunts, which you can learn about on our Liver Diseases Page.

Return to Feline Diseases Page

 

 

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Spleen Hematoma

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This page stresses the importance of routine yearly exams, and close owner observation, on our pets. Large breed dogs can be stoic, and have significant problems brewing without showing any outward signs. When serious symptoms like weight loss and lack of appetite finally show up, the disease process is usually well entrenched, and there is little we can do. We want to see these pets before it gets to that stage.

Pets are masters at hiding illnes, so it can be difficult if they are ill. It might be a good idea to read our short page on symptoms of disease to know what to watch for.

We also have a nice page on teaching you how to do an in-home exam. If you bring your pet to us one of our staff will go over this with you, and do a hands-on demonstration of how to palpate the peripheral lymph nodes. This early warning system is a great way to catch problems early in the course of disease.

History

A beautiful male labrador retriever named Colt came in for a routine Wellness Exam when he was 10 years old. During this exam Colt’s owner told Dr. Palazzolo that Colt vomited on occasion over the last month, but that otherwise he was doing fine. He is a calm dog, and just lays around a lot.

Exam

Colt’s body temperature was normal, and his weight was the same as a previous visit. A pet’s weight is a good idea of how well it is doing, and if it is maintaining its weight that is usually a good sign. In Colt’s problem, this is not the case.

During the physical Dr. P noted a very tense abdomen, so tense that he could not even palpate internal organs. After this was noted, the owner did say that Colt’s abdomen seemed to be distended. The rest of Colt’s thorough physical examination was normal.

The distended abdomen is a significant finding, and warranted a radiograph, in addition to the blood panel which is part of the Wellness Exam.

Diagnostic Tests

ColtRad

You don’t need to be a radiologist to know something is wrong with this abdomen, as evidenced by the large and round whitish structure

NormalAbdDogRad

Here is a normal abdomen for comparison. In this normal radiograph you can see individual organs, unlike the abnormal one above, that looks like it has a beach ball inside of it.

This is a serious finding, and this mass could have many causes, and involve almost any internal organ. Due to its size, shape, location, and the relative lack of symptoms, it was probably the spleen. It could be a benign tumor of the spleen called a hemangioma, a malignant tumor of the spleen called a hemangiosarcoma, or a hematoma of the spleen. A hematoma is a blood filled cavity that is benign.

Its size said it might be a hematoma, which has the best prognosis of the three. To learn much more about spleen tumors please visit our hemangiosarcoma page.

ColtCleanChest

Before we proceed any further we take a radiograph of the chest to make sure there has not been any spread of tumor to the lungs. The white object in the center is Colt’s heart, the dark areas around the heart are the lungs. This is a normal chest radiograph.

You can learn much more about how to read a radiograph if you are interested

Our radiologist, Dr. Ann Reed, performed an ultrasound of the abdomen. This ultrasound lets us know if the mass is actively bleeding, and if there has been any spread of the mass to the right atrium of the heart. If that is the case, the mass is probably a hemangiosarcoma that has already spread. This is not a good prognosis.

ColtUS

Colt’s ultrasound report showing it is probably benign, and consistent with a hemangioma or hematoma

Pre-surgical Preparation

In Colt’s case there was no abdominal bleeding, and the heart was OK. Colt’s blood panel came back normal, so we did a cross match of his blood, and readied a unit of blood for a transfusion in case we needed it during the surgery scheduled for the next day.

Agglutination Crossmatch substrate Crossmatch blood Transfusion kit
BloodCrossMatch2 BloodCrossMatch1 BloodCrossMatch3 spleen-transfusion

Before we do a blood transfusion we do several tests to minimize a transfusion reaction

We were much better prepared for surgery the next morning with all of this information. During the night prior to surgery Colt was given intravenous fluids to stabilize him and make him a better anesthetic risk, and a pain patch was put on. Having the pain medication on board before surgery increases its effectiveness. Colt is now good to go for surgery the next morning.

We have a short page that talks all about how we do surgery at the Long Beach Animal Hospital. You might want to check it out before you see Colt’s surgery.

Graphic and bloody photos of surgery to follow

Colt did great overnight.  We took away his popcorn after the Lassie movie ended (he likes classic movies), and he rested comfortably during the night, monitored by our night crew. He slept well, and dreamed of being a famous movie star like Lassie.

ColtJenn

 Here he is with Jennifer the next morning, keeping an eye on our surgical team as they prepare for his surgery.

KennedyExam

Colt gets some extra petting for being a good boy, by his surgeon, Dr. Kennedy

KennedyExam1

Even though Colt has been thoroughly checked, we always perform a physical exam just prior to inducing anesthesia. An important organ to assess is the heart. If we suspect something is wrong with the heart when we listen to it we will do a pre-anesthetic EKG (electrocardiogram).

If you like heart stuff we have a very detailed page on heart disease in animals. It’s not for the “weak of heart” (pun intended), because it goes into all sorts of anatomy and physiology. If you get through it give yourself a pat on the back, and think of applying to veterinary school!

Propofol

Colt’s anesthesia is initially given by injection. Once he is relaxed we put in a breathing tube and start prepping his abdomen for surgery.

surgery-monitor

This surgical monitor allows us to detect any impending problems, and make adjustments before problems become serious.

Rabbit-femurfx-9

Even though we use these hi-tech machines to monitor important physiologic parameters during surgery, we also use the hands-on approach to make sure we do not miss anything. In this picture our anesthetist is listening to the heart with a stethoscope.

AnesthesiaReport

During the procedure Colt’s vital information is closely monitored and recorded. Our anesthesia page has more details.

Instruments

While Colt is being readied for surgery Dr. K is getting her instruments ready. She will need many clamps to close off the blood supply to the spleen before it can be removed, which required more than one surgical pack.

draping

When Colt is prepped, and under the proper plane of anesthesia, Dr. Kennedy does her draping. This draping is an important part of the surgery, and is doing carefully.

JessicaTerri

It will take more than one pair of hands to get this spleen out, so our surgical assistant, Jessica, stands by waiting for instruction. Terri our anesthetist keeps a close tab on everything.

Incision1

The initial incision is only though the skin. Blood vessels just under the skin are clamped before we go any further.

Incision2

You can see the two clamps that are controlling bleeding in the subcutaneous (SQ) tissue just under the skin. Colt’s spleen is humungous, so it will take a long incision to get a big enough opening to remove it

Incision3

Even though the incision was made as long as possible, the opening was still not big enough to remove the spleen. Dr. K had to make a side incision in the abdomen to facilitate removal.

SpleenBloodSupply

The spleen has an extensive supply of blood vessels that are near the stomach. A large part of this surgery is identifying and ligating these vessels, and doing this without damaging the blood supply to the stomach. These blood vessels are intertwined in tissue that is covering the spleen as the body attempts to wall of this large mass. This is the most meticulous part of the surgery, and Dr. K’s experience and skill at doing this before pays off.

LargeVessel

These blood vessels are large and need to be handled carefully

ClampingVessles

It takes multiple clamps and special suture material to perform this important part of the surgery

JessicaHoldingClamps

Jessica is kept busy holding clamps while Dr. K identifies and continues to ligate the many blood vessels to the spleen

FirstRemovalAttempt

As more of these vessels are ligated Dr. K carefully attempts to get the spleen out of the abdomen. No luck the first time.

Adhesion

An adhesion from the intestines to the spleen was identified and removed. Time to try to get the spleen out again.

SecondRemovalAttempt

 We need to be very careful at this point that we do not rupture the spleen by forcing it out.

FirstRemovalAttempt

With gentle coaxing and manipulating, along with Jessica’s help holding the abdomen open, we almost have it out, but not just yet

ThirdRemovalAttempt

It was time for Dr. P to stop taking photos and assist in surgery. He has removed many spleens in his decades of surgery, and with the help of Dr. K and Jessica, was able to extricate the spleen. Now Dr. K could finish ligating blood vessels (and hopefully Jessica does not need to scratch an itch at her nose)!

JessicaHolding

Here she is doing a great job

FinalCut

The final blood vessel to the spleen is cut while Jessica holds on to the spleen

JessicaHoldingFinal

After almost 2 hours of surgery Colt is now lighter on his feet

FourteenPounds

It’s official, 14.095 pounds!

SpleenHematoma

The vertical and long structure on the left is an enlarged and normal spleen, with the hematoma of this spleen on the right

Lavage

Surgery is nowhere near done. After Dr. K looks for any significant bleeding on the blood vessels she ligated, she flushes the abdomen numerous times with warm saline.

LineaSutures

The long process of putting Colt back together now begins. The most important suture layer is an area called the linea alba. This is where the muscle bellies of the abdomen meet, and is a tendinous area that is very strong. This is where the first and most important layer of sutures is placed.

SkinSutures

After more layers of sutures are placed, and before Dr. K puts in skin staples, Colt now has a bikini scar (OK, maybe not, but once the hair grows back nobody will know his secret)

Local

In addition to the pain patch put on the night before, and the pain injection given during surgery, a long acting local anesthetic is placed at the incision. Now Colt will be comfortable when he wakes up and through the night.

LocalStaples

All of our abdominal surgeries receive therapy laser treatment on their incisions. This aids in both healing and pain control. Notice the staples in Colt’s skin incision.

FirstBandage

Now comes the bandage; the first layer is gauze and telfa pads

SecondBandage

After more pads and gauze are put over the incision, the outer layer is wrapped by Terri while Jennifer and Jessica hold up Colt. They are getting their biceps exercise for the day!

LastBandage

We did the surgery the day after Halloween, so we thought this was an appropriate colored bandage

Trophy

Our dedicated surgical team posing with their trophy. Great job!

Colt was closely monitored for several days, and his red blood cell count was checked to make sure he did not need that blood transfusion. He went home after 2 days and was back to normal in no time. Yea Colt!

HemangiomaReport

Great news on Colt’s histopathology report, confirming it is a hematoma. Colt should make a complete recovery and lead a normal, if not lighter, life.

HemangiomaHisto

Just in case you want to see what a spleen hematoma looks like under the microscope here is your chance

047A8608

Colt with his happy mom two weeks later when he came in for his staples removal

 Case Summary

If you go back to Colt’s initial history the owner stated Colt vomited on occasion over the last month. Looking at the size of this hematoma (a record for Long Beach Animal Hospital), the hematoma was probably brewing over several months. Its a wonder Colt could even eat, and was not vomiting more, with a hematoma of this size in his abdomen. If Colt had not been brought in for his Wellness Exam, this hematoma could have easily ruptured, causing Colt to go into shock. and most likely a rapid death.

 Colt’s weight was the same as a previous visit. It was only because he had such a large mass in his abdomen, and goes to show you cannot go by just one physical parameter to determine health. It also shows you need to be thorough when investigating a medical problem.

The ability to do ultrasound with our highly skilled radiologist, telling us the hematoma was not actively bleeding, allowed us to take the time to prepare Colt for surgery. This made him a much better anesthetic risk, and and allowed him to heal faster with no complications.

The ultrasound told us it was probably a hematoma, and there was no evidence of spread to the heart which would indicate a potential malignant hemagiosarcoma of the spleen. With the blood panel and chest radiographs being normal, it was realistic to proceed with surgery based on the fact that the mass was probably not a malignant cancer.

Now that you have seen a successful hematoma surgery, now might be a good time to learn about hemangiosarcoma, a malignant cancer of the spleen. In this same page you can see another hematoma surgery of a dog with an 8 pound hematoma of the spleen.

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Inflammatory Bowel Disease (IBD)

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IBD is an inflammatory condition of the stomach, small intestines, or large intestines (the gastrointestinal (GI) tract).  It is sometimes called Idiopathic IDB. The Idiopathic part means that the cause of the condition is unknown.

IBD tends to be chronic in nature.  It is one of the most common conditions of the gastrointestinal tract diagnosed in pets, especially in cats. Despite its prevalence, it is one of the least understood conditions, especially regarding cause. Some pets respond well to treatment, others do not.

Some cases of IBD involve the liver and pancreas. In this case there are 3 diseases occurring, and we refer to it as Triaditis. This is more difficult to treat than IBD alone.

The usual symptoms of IBD are poor appetite, vomiting, diarrhea, and weight loss.  Cats tend more  towards vomiting, dogs tend towards diarrhea. These symptoms appear in many other diseases, so you cannot assume your pet has IBD from symptoms alone. To learn the process of how we make a diagnosis of a disease when the symptoms are the same as so many other diseases, we have a methodical and detailed approach. It is called the Diagnostic Process.

We discuss the importance of worms (internal parasites) many times in this page in regards to IBD. With the modern medications we have, including flea products that contain medication to kill worms, it behooves you to treat your pets for worms monthly. Not only might it help prevent IBD from appearing at some time in your pet’s life, it will protect you and your children. Our Internal Parasites page has the scoop on all of this.

In spite of its prevalence, many pets are diagnosed with Idiopathic IBD when they do not have it. To standardize what IBD is, the World Small Animal Veterinary Association has listed the following criteria to help make this diagnosis:

The GI symptoms must be present for at least three weeks

Diet change, worming, and medication do not give a significant reduction in symptoms

No other explanations can be found for the symptoms

Biopsies of the intestines show significant inflammation of the interior lining

The resolution of symptoms when put on mediations that modulate the immune system (immunosuppressive).

This criteria means that a pet that responds to just a diet change technically has a Food Responsive Enteropathy. If a pet responds just to antibiotics then it technically has an Antibiotic Responsive Enteropathy.

Graphic photos of surgeries are on this page

Anatomy and Physiology of the Gastrointestinal (GI) Tract

When your pet eats, food from the stomach passes into the small intestine, which is composed of three different sections called the duodenum, jejunum, and ileum.

The majority of nutrient (proteins, carbohydrates, fats) digestion occurs within the small intestines.  The inner lining of the intestines is called the mucosa, and that’s where all the action occurs when it comes to absorbing nutrients. The mucosa has a large surface area because there are microscopic folds called villa.

Ilium-NormalMucosa

This is the lining of the small intestines. The villa are microscopic, so you cannot see them without a microscope.

There are many different types of specialized cells in the lining of the mucosa. Some of these cells specialize in aiding digestion, some are for absorption of these nutrients into the bloodstream, and some are part of the immunes system and defend the body from foreign invaders.

These immune system cells are important for protection due to the constant exposure the GI tract has to outside invaders in the form of oral ingestion of food and its many contaminants. It is these cells that can overreact and cause IBD symptoms.

Surgery-SmallIntestines

These are the small intestines during a routine abdominal surgery. Notice the extensive blood supply, necessary to get those nutrients from the lining of the intestines into the bloodstream, and then off to every cell in the body- amazing!

Ilium-Ingesta

This is what the ingesta looks like as it passes through the small intestines

The pancreas secretes digestive enzymes into the small intestines as the food passes through the duodenum. These enzymes are crucial for digestion of fats, carbohydrates, and proteins. As the food continues down the small intestines the enzymes from the pancreas continue their breakdown of nutrients, which are then absorbed by the mucosa of the jejunum and ileum and make it into the bloodstream.

Pancreas-labeled

This is the pancreas, a small but mighty organ. Our surgeon is holding the duodenum (D), with the pancreas in the center (D).

Pancreas-Normal

Close up view of the architecture on the outside of the pancreas

The gall bladder secretes bile into the duodenum to help in digesting fats. When the liver is a part of IBD the bile can build up in the liver and cause a problem. This is a part of the Triaditis that complicates IBD.

The large intestine is composed of the cecum (our appendix), colon, rectum, and anus. Water, electrolytes (sodium and potassium), sugars, and vitamins are the main nutrients absorbed by the large intestine. Some vitamins are produced in the large intestine also. Nutrients that were not broken down or absorbed well enough within the small intestine are further digested in the large intestine due to microbial fermentation. The large numbers of these good bacteria that are present in the intestines are crucial to normal health.

The human cecum (appendix) has atrophied to the point that it is no longer needed. Our diet does not have the fiber of our ancestors, so this organ is not needed for normal digestion, which is why it can be removed if appendicitis occurs. As a fun anatomical comparison, the cecum of a rabbit is enormous in relation to the rest of its body. That is because it is a hind-gut fermenter, and contains large numbers of bacteria to help digest food that is high in fiber. Our rabbit GI stasis page has radiographs of the cecum along with actual pictures to give you an idea of just how large it is.

Pathophysiology

Allergens cause inflammation of the mucosa, leading to the symptoms associated with IBD. The allergens that cause this inflammation can be anything, with food (especially protein) as the main culprit.  Bacteria and parasites are also allergens that cause inflammation of the mucosa. It is the immune system that over reacts to these antigens that causes the symptoms of IBD. This immune system over reaction is why pets that truly have IBD need medication to suppress the immune system, in addition to dietary changes and antibiotics.

Intesinte-normal lumen

The size of the lumen thorough with the food passes and intestinal wall thickness of a normal small intestine

ThickenedSmallIntestine

You can easily see the smaller lumen and thickened intestinal wall in this pet with IBD

Inflammation of the pancreas is known as pancreatitis. In pancreatitis, the digestive enzymes that would normally be secreted into the duodenum to digest food are now leaking out of the pancreas into the abdomen, causing tremendous inflammation and pain to surrounding organs. Pancreatitis is a serious disease, and usually requires hospitalization, intravenous fluids, and medication. It can be hard to diagnose in cats because they usually become quiet and sit as if content, when in reality they are in pain. A clue is the fact that are not eating well.

Inflammation of the liver in some cases may be associated with IBD, permitting an infection to creep up the bile duct and into the liver. There are many different sources to this infection, ascending from the GI tract or urinary tract.

The pancreas, liver, and intestines are closely associated, and when one has a problem it causes inflammation in one of the other ones. When all three have a problem it is called Triaditis. As you can see, it all gets quite complicated.

Cause

IBD is one of those conditions where the exact cause might never be identified. The most common causes are dietary allergies, infections, and environmental stress. Stress can happen in multiple pet households, during holidays, and in extreme weather.

Dietary allergies are involved with sensitivity to protein in the diet. Sometimes, an inability to absorb nutrients, called a malabsorption syndrome, is involved. Some pets generate an excessive amount of a specific white blood cell called an eosinophil (eosinophil gastroenteritis) in the lining of the GI tract.

Other dietary causes might include artificial coloring, preservatives, and food additives. Differentiation between the above-mentioned causes is difficult, especially since many IBD cases are associated with several concurrent factors.

It is suspected that puppies with a large amount of internal parasites (worms) are setting the stage for IBD later in life. This is another good reason to have your pet checked for internal parasites at least yearly, and wormed frequently when young.

Pancreatitis is highly associated with pets that are overweight, particularly spayed female dogs. Fatty meals are important components of the clinical history for cases involving pancreatitis. As a result, we tend to see this cause of pancreatitis around the holidays when people are celebrating with turkey (and gravy) and other similar foods that their pets’ eat also.

Inflammation of the pancreas can spread to the liver  due to its proximity.  This can inflame the gall bladder, causing bile to backup into the liver. This can lead to Triaditis mentioned earlier.

Inflammation of the liver and biliary system, known as cholangiohepatitis, is most commonly associated with a bacterial infection.  In cases of Triaditis, it is unknown as to whether the liver is the first organ affected, resulting in secondary inflammation of the pancreas and gastrointestinal tract, or if it is the other way around.  It has been hypothesized that bacterial infections may be the initiating cause of cholangiohepatitis, with IBD and pancreatitis following thereafter.

Dietary Induced

Proteins and grains in the food contribute to dietary intolerance. Intolerance occurs when there is an abrupt change in the diet, resulting in an inability for the gastrointestinal tract mucosa and associated cells to adapt accordingly.  When this happens foods are often not digested or absorbed properly.

Maldigestion is a separate condition of the gastrointestinal tract that generally occurs secondary to exocrine pancreatic insufficiency. The endocrine pancreas secretes insulin to regulate the blood glucose level. The exocrine pancreas secretes the digestive enzymes needed to digest food in the intestines. If the pancreas is not secreting enzymes into the small intestines as the food passes, the nutrients will not be broken down and absorbed into the bloodstream. This leads to weight loss and diarrhea, even in a pet that is eating.

Malabsorption is secondary to numerous disease processes such as food allergies and/or intolerance, protein losing diseases of the gastrointestinal mucosal layer, intestinal parasites, antibiotic responsive disease, cancer, IBD, and immune-mediated disease. The exocrine pancreas is secreting the proper digestive enzymes in this cause. It is an inflammation of the inner lining of the intestines (the mucosa) that prevents absorption of the nutrients into the bloodstream.

Intestinal parasites (worms)

There are numerous intestinal parasites known to cause the same symptoms as IBD. They include roundworms, hookworms, whipworms (dogs only), cryptosporidia (protozoa), toxoplasma (protozoa; cats only), coccidia, and giardia.

Some intestinal parasites are known to affect humans as well (zoonotic potential). These include the larvae of roundworms causing organ involvement (visceral larval migrans), or eye involvement (ocular larval migrans), hookworms (skin involvement), giardia (gastrointestinal disorders), coccidia (gastrointestinal disorders especially in immune suppressed individuals), toxoplasma (congenital defects in babies), and cryptosporidia (gastrointestinal disorders).

A fecal examination is often one of the first steps when diagnostics are being evaluated in a pet with a gastrointestinal disease. Our intestinal parasites page has detailed information on these parasites (worms). We sometimes do  a fecal Giardia test since this parasite can be hard to detect.

Cancer – Lymphosarcoma (Lymphoma)

In cats, lymphosarcoma is the most common type of cancer known to affect the gastrointestinal tract. This is not easy to diagnose, since the changes present in IBD are very similar to those in Lymphosarcoma when the pathologist analyzes them under the microscope.

Depending on the type of lymphoma (small, medium or large cell lymphoma), tissue samples must be sent in for further diagnostics in order to definitively differentiate between early cancer and IBD. Proper treatment depends upon a proper diagnosis.

VeryThickenedSmallIntestine

These severely thickened intestines are from cancer

We have a page that shows an exploratory surgery on a cat with intestinal cancer.

Bacterial infection

Although there are no definitive infectious agents that consistently result in IBD, some organisms such as Giardia, Salmonella, Clostridium, and Campylobacter could be a cause. Some of the “good” bacteria, those that are necessary for life, can become imbalanced and cause the symptoms seen in IBD.

Medications

Any medication can disrupt the lining of the intestines. The most common one is antibiotics, since they disrupt the normal GI bacteria (referred to sometimes as flora).

Other causes

Toxicities (plants, chemicals), hyperthyroidism, FIP, FeLV, FIV .

Diagnosis

Signalment

Both dogs and cats are commonly affected by IBD, although it is much more of a problem in cats. IBD can occur at most any age due to the numerous causes of the condition; however, it is usually observed in pets over the age of two .

Triaditis is more commonly diagnosed in middle to older aged cats.  If it is associated with a food allergy, they tend to be young adults to middle aged. Males and females get IBD in equal frequencies.

Addison’s disease, which is common in Standard Poodles, can cause symptoms similar to IBD.

History

Sometimes pets are affected by IBD for many years while appearing apparently healthy in all other aspects. Typical symptoms are  lethargy, poor appetite (anorexia), weight loss, diarrhea and vomiting.

Depending on the inciting cause, the clinical signs may occur intermittently over a long period of time (i.e. dietary allergy) or abruptly and progressively (immune-mediated, infectious, dietary allergy, cancer). If Triaditis is present clinical signs may range from lethargy and decreased appetite to severe vomiting, diarrhea, abdominal pain, and icterus (jaundice) due to liver compromise).

OLYMPUS DIGITAL CAMERA

This pet has severe icterus (also known as jaundice)

Cats can have variable symptoms compared to dog. Cats that have pancreatitis might sit quietly and appear to have no problems. In reality, these cats are painful, which is why they sit like this.

Physical Exam

In both dogs and cats, palpation of the abdomen might reveal painful and thickened bowel loops. This is not a consistent sign, and just because bowel loops are thickened, does not mean there is a problem. Pain may also be associated with palpation of the pancreas or liver in cases of Triaditis.

Lymph nodes deep within the abdomen may be enlarged and palpable as well as painful. Excessive intestinal sounds (called borborygmus ) might be heard on auscultation of the abdomen. In more chronic cases, other subtle signs may be present such as a dull hair coat, mild to moderate dehydration, fever, and overall poor body condition. None of these are consistent findings, and cannot be relied upon for a diagnosis of IBD.

XRays-LymphNode

These lymph nodes, call the sub lumbar, are enlarged on this dog. They are the whitish circles within the red circle. They are due to cancer, but they cannot be palpated.

Diagnostic Tests

Complete blood count, biochemistry panel, and urinalysis, are a starting point for diagnosis. Certain blood values might suggest IBD if in combination with clinical signs. Even “normal values” are clinically diagnostic, as they help to rule out another disease that can cause the same symptoms as IBD. A pet with a perfectly normal blood panel can still have IBD.

Some pets will have a chronic anemia (low red blood cells). Sometimes the white blood cells will be elevated, in other cases the protein will be low (hypoproteinemia). There might also be a low cobalamin level.  Cholangiohepatitis (inflammation of the liver) in cats, when Triaditis is present, may be further suspected if bilirubin (hyprebilirubinemia) or liver enzymes are increased. A bile acids test helps assess the liver in these cases.

LiverTests

The blood panel is very thorough and checks many different organs and systems. This is a few of the many tests, the elevated liver tests are circled, and could be a sign of Triaditis in this case.

A resting cortisol test might also be used to eliminate Addison’s (hypoadrenocortocism) disease

Fecal examination is an important and inexpensive test to rule out internal parasites (worms). We sometimes give worm medication (called anthelmintics) to pets with a negative fecal if they have and GI symptoms. This is because a pet can have internal parasites that do not show up on a fecal exam. Our intestinal parasites page has much more information explaining this.

A fecal exam, checking for internal parasites (worms) is important in every pet with any signs of illness. In this exam, we are checking for eggs (ova) of the parasite. A special test for Giardia is also used. 

Bacterial cultures are also utilized in some cases. The bacteria we are checking for include:

Campylobacter

Salmonella

Cryptosporidium

This is what we want to see when we do a urine culture- no bacterial growth in 48 hours

Abdominal radiographs are often normal in cases of IBD, but are a necessary tool to rule out other causes of similar clinical signs. Survey abdominal radiographs are also indicated prior to ultrasound  as well.

Xray-PenniesInRectum

This dog had chronic diarrhea.  Nobody took a radiograph prior to treatment. The cause was not IBD, it was the pennies stuck in the rectum.

IBDRadiograph-thickened intestines

This cat has IBD, as evidenced in this case by the thickened small intestines at the arrow. This can also be a normal finding, and it can also be a sign of intestinal cancer. The more common intestinal cancers are lymphoma, adenocarcinoma, and mast cell tumors.

Prior to the common use of ultrasonography, barium contrast studies were performed in order to reveal disruptions of the mucosal surface along the gastrointestinal tract.  We are looking for filling defects and ulcers of the mucosa and thickening. Barium has lost some of its significance since ultrasonography tends to be much more sensitive. One very nice “side effect” of giving barium to a pet that might be vomiting is its soothing affect on the lining of the intestines (mucosa) to stop the vomiting.

TLI type tests- serum fPLI (pancreatitis), fasting serum TLI (exocrine pancreatic insufficiency), fasting serum cobalamin and folate (small intestinal function and bacterial overgrowth). These are specialized tests and take several days for the results to come back.

Endoscopy is a useful tool since we can observe the lining of the esophagus, stomach, and duodenum for ulcers, lesions, and foreign bodies, that might not show up on a radiograph. Biopsy samples can be taken, although they are not full thickness, and only take the lining of the small intestines. This can lead to an inaccurate diagnosis.

This is a report from a stomach and intestinal biopsy with the endoscope

The most accurate way to diagnose IBD is to perform an exploratory surgery and take full thickness intestinal biopsy samples. If the blood protein level is low (hypoproteinemia) care must be taken because healing can be delayed.

Samples obtained during surgery are analyzed by a pathologist to help confirm a diagnosis of IBD, and also rule in or rule out the possibility of  intestinal cancer. Sometimes  the pathologist cannot tell the difference between IBD and cancer due to the abundance of inflammatory cells. During surgery, samples of other important organs like the liver and lymph nodes can also be obtained. These samples are very informative, and are taken in many cases.

IntestineBiopsy

Surgery has the major advantage of being able to see and palpate the intestines, along with taking a complete (called full thickness) sample of the intestines. This surgeon is using a scalpel blade to take the sample.

These samples are analyzed by a histopathologist. The report might come back with several different terms describing the IBD in specific medical terms, depending on the cell type:

  • Lymphocytic-plasmacyltic (the most common one)- respond best to diet change, antibiotics, and immunosuppressive drugs.
  • Eosinophilic (2nd most common)- respond best to worming medication, diet change, and sometimes immunosuppressive drugs
  •         Neutrophilic- bacteria is a possible cause, so culture and antibiotics, with no immunosuppressive works best
  • Granulomatous- least common, suggests fungal or intra-cellular pathogen

Ultrasonography of the abdomen is an invaluable diagnostic tool. Prior to the advent of ultrasound, exploratory surgery was needed to make an accurate diagnosis, and that was only after biopsy samples were obtained. Ultrasound is dramatically less invasive and expensive compared to surgery, and the results are obtained immediately in many cases. In the case of IBD it can tell us of thickening of the intestines and gives us a suspicion that IBD is indeed present, but it cannot confirm the diagnosis.

Ultrasound is a big aid in the diagnosis of IBD in its ability to to rule out cancer and foreign bodies as a cause of vomiting. It also gives us an accurate way to biopsy internal organs like lymph nodes.

Ultrasound-Machine

Ultrasound is rapid and painless, and the only invasive part is shaving your pet’s abdomen

UltrasoundReport-IBD

This is a typical report of a pet with IBD. Note how detailed it is, and how organ size is measured. 

Ultrasound can be used to measure wall thickness of various segments of the intestinal tract, which yields supportive evidence in the face of clinical signs. However, it cannot be used to differentiate between IBD and other disease processes that result in significant inflammation of the intestinal wall (i.e. lymphoma). This is where surgery has an advantage since full thickness biopsy samples can be taken for analysis

Ultrasound-SmallIntestine

This is what the small intestines look like during ultrasound while they are being measure for size

Ultrasound-Pancreas1

This is what the pancreas looks like, also being measured

Ultrasound-MesLymphNode

All of the abdominal organs are assessed during an ultrasound. This is what an enlarged abdominal lymph node looks like.

Fine needle aspirate samples may be obtained with the guidance of ultrasonography.  Sometimes this test is diagnostic, sometimes it is not. Even though it is not a perfect test, we sometimes recommend it due to the simplicity in obtaining it.

A hypoallergenic diet trial may be issued for cases of highly suspected dietary allergies or intolerance. In such cases, some pets respond when the diet is altered and no further diagnostics are necessary. You must feed this food, and only this food, to see if this works. Sometimes results are immediate, other times it might take several months to know for sure.

This can be a risk if the diet trial is attempted before numerous other disease processes are not first ruled out, especially cancer and internal organ diseases like Feline Hyperthyroidism.  This delay in diagnosis can affect outcome. If clinical signs do not improve or resolve within the first two weeks of the diet trial, then further diagnostic work-up is indicated.

Treatment

Depending on the severity of disease at presentation, treatment must first begin with stabilizing the pet. What we do to stabilize depends on the severity and duration of symptoms.

Symptomatic

Stabilization generally includes intravenous  fluids to correct dehydration, correct electrolyte imbalance, and improve kidney function. If the protein level is low we might use a fluid called Hetastarch.

Pets that are not eating are assist fed a special diet called A/D to maintain appropriate caloric intake and to prevent further disruption of internal organ function and get the GI tract back to normal. Probiotics to help stimulate the normal bacterial flora might be beneficial.

Vomiting pets are continued on fluids to maintain normal hydration, and given a specific medication called Cerenia (maropitant) to stop the vomiting. This drug has been a tremendous help in alleviating vomiting in pets due to many different causes. We use it for IBD and also for other GI problems like parvo virus and pancreatitis without IBD. Cerenia works on the emetic (vomiting) center of the brain.

Cerenia

We use the injectable version in the hospital, and send home an oral version if needed

Diet

It must be understood that if one of our doctors recommends a dietary change to treat your pet’s IBD that the only food or treat that can be fed to your pet is this new diet. Nothing else can be used as a food source. Feeding other foods is a reason why this dietary change does not work in some cases. When multiple people feed a pet this needs to be communicated to everyone.

Dietary intervention is considered a mainstay for many gastrointestinal cases because a large proportion of cats and dogs with gastrointestinal disease are associated with food-sensitivity. We need to get these pets eating again for the intestines to return to normal function.

Dogs and cats with pancreatitis, which is painful and causes severe illness,  do well initially with a low fat diet in the early stages to get them stronger and get the intestines used to digesting food again.  I/D (Intestinal Diet) has been used by our doctors for well over 35 years, and is the gold standard for pets with GI problems. After the pet is stable we look for a long term food.

PrescriptionDiet-ID

I/D comes in many variations, and our doctors will tell you which one is appropriate for your pet’s specific problem

Hydrolyzed Protein Diet

 It is the protein component of the food that causes the problem in IBD. Hill’s has solved this problem by making a food with a hydrolyzed protein that does not cause a reaction. It is unconditionally guaranteed, and is worth using in every case because it works often, and you can get your money back if it does not work. This is a complete diet and can be fed for the rest of your pet’s life. It is very rewarding when a dog or cat with the signs of IBD improves on only food and does not need medication.

PrescriptionDiet-ZD

The best food we have found overall for dogs and cats with food allergy is called Z/D

Novel Protein Diets

Novel proteins are not manipulated protein sources (as compared to hydrolyzed proteins like Z/D), but are simply new proteins that the pet has never ingested before. Many dogs and cats immune systems have not been exposed to venison, duck, or rabbit. Due to the fact that it takes long-term exposure to a protein before the immune system will react against it, then these novel protein diets are often attempted when the protein source is suspected to be the cause of IBD. The new diet will take at least 2 weeks, and up to 4 weeks, for the symptoms to diminish or resolve.

These foods might contain:

Potato

Duck

Sweet potato

Venison

Salmon

Vitamin supplementation is a critical component of treatment for some individual pets whose IBD stems from a deficiency in cobalamin (vitamin B12), specifically in cats.  Pets that are sick enough to have a low cobalamin level are generally in need of more than just vitamin supplementation, requiring a combination of other medications and dietary alterations.

Immune Modulators

Steroids (corticosteroids) are used in many cases in order to decrease the inflammation. The most common ones include prednisolone or prednisone. Budesonide, is a weaker steroid, that is also used. If the root of IBD or Triaditis is due to an immune-mediated process, then more potent immune system suppressants than steroids are required, such as cyclosporine, chlorambucil, or azathioprine.

Cyclosporine is an immune modulation drug that can suppress the inflammation from IBD.

Chlorambucil (Leukeran) is a chemotherapy drug for treatment of resistant IBD or some forms of cancer

Antibiotics

Antibiotics should be chosen based on bacterial culture and susceptibility when possible, especially in cases of Triaditis. Antibiotics such as Flagyl (metronidazole) are very commonly used for their ability to treat patients with chronic diarrhea. Some pets respond well to this medication only (they have Antibiotic Responsive Enteropathies). Flagyl suppresses the bacteria that are involved with IBD, and also mildly decreases the immune response that is an important component of IBD. Other antibiotics include Tylosin, Amoxicillin, and Fluoroquinolones. Tylosin must be compounded.

Probiotics and Probiotics

These are commonly used to help with the trillions of beneficial bacteria in the GI tract. IBD disrupts these “good” bacteria, and even the antibiotics we use to treat IBD can disrupt the normal GI flora. Make sure there is not a chicken or beef base.

Probiotics have bacteria that are considered to be beneficial to the GI tract. Probiotics have fiber that is fermented for good bacteria.

Liver Support Medication

When the liver is involved (Triaditis) we might also use Actigall (ursodiol) or Denamarin (s-adenosyl methionine)

Denamarin

IBD can be painful, and it is important to keep the pet as comfortable as possible during an acute episode of IBD or severe case of Triaditis. Prednisone, prednisone, and Flagyl decrease inflammation, which helps minimze pain. Specific pain medications are also used.

Stem Cells

Limited studies show promising results

Fecal Transplant

A last resort that can be effective. The feces must be negative for pathogens.

Prognosis

The prognosis depends on many factors. This disease is usually not cured, unless there is a food allergy and we find the right diet for your pet. Most cases are controlled with diet and medication. IBD and it’s associated diseases tend to be a long-term problem that is usually managed successfully. You increase your chance of success by giving medication consistently and bringing your pet to us for exams and diagnostic tests to look for changes that require a change in treatment.

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C-Section

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A  Caesarean Section (abbreviated as C-Section) is derived from the latin word “caedare”, which means to cut. It is believed that Julius Caesar was the first to be born this way when his mother died during childbirth. Most scholars of ancient history believe this was done long before Julius Caesar was born. Either way, the name sticks.

Our patient is a female dog that was able to deliver 2 pups normally. When we examined her and palpated her abdomen we could feel another puppy. She is exhausted, and has what is called uterine inertia. Her uterus does not have the strength to deliver the last pup.

Her 3rd one was stubborn though and did not want to come out, so we had to go in and convince him the time had come to meet his siblings. We routinely perform a spay (OVH) on these dogs after we remove the pup.

Graphic photos of an actual surgery are on this page. 

Radiograph-pregnant dog lateral

We took a radiograph to confirm the size of the pup and look for any problems

Pup-nursing help

The two that were born naturally had one last meal from their mother before we brought her into surgery

Pups-sleeping in carrier

After their meal they were cozied up with blankets and a hot water bottle (at the bottom of the photo) since they cannot regulate their temperature at this stage

Pups-sleeping

We know they were content because they fell asleep. Now we could concentrate on their mother and the remaining pup

It was time for the C-section. After we gave the mother a thorough pre-anesthetic exam, and administered intravenous fluids, she was ready for surgery. In this procedure we move fast, real fast, so the remaining pup is not depressed by the anesthesia we give the mother for the C-section. While the surgeons are scrubbing in and preparing their instruments we are preparing the mother for surgery.

Joel-mother

After she was clipped Joel brought her in to start the anesthesia

Mother-onside

She is getting sleepy as we administer her anesthetic. As soon as she is out we move her into surgery. Her abdomen has alreadly been clipped, and a local anesthetic has been infused into her abdomen where we will make our incision. This allows us to give her less general anesthetic and not depress the remaining puppy.

Hands

While our patient is being anesthetized our surgeons are scrubbing up

Instruments

As soon as the surgeon’s are gloved and gowned they go right into the surgery suite to get the instruments ready. We do not want our patient waiting for the surgeons, we want the surgeons waiting for the patient.

Surgivet

Our patient is immediately hooked up to our anesthetic machine when brought into the surgery suite. When stable we can start the surgery.

Surgeon-draping

Dr. Wood, our first surgeon, wastes no time draping our patient for the procedure once our anesthetist confirms our patient is stable

Doctor-draping

At this point, our 2nd surgeon, Dr. ridgeway, is scrubbing in and will be in the surgery suite in a few seconds

Doctor-surgery team

We don’t technically need 2 surgeons for this procedure. We do it because we can get the puppy out of the uterus faster this way, which is of utmost importance to us for a pup that has been in the uterus longer than it should be and could be struggling.

Pup- in uterus

This is what the pup looks like in the uterus

Uterus-incision

A quick incision in the uterus, taking care not to cut the puppy

Uterus-pup out

Out he (it’s a boy!) comes covered in a protective membrane

Pup-umbilicus clamp

Once we remove the membrane the first thing we do is clamp and cut his umbilical cord

Pup-suction

We immediately suction out any fluid from his mouth so he can get some air into his lungs

Pup-nurse suction

Then it’s a quick hand-off to our nurses who are eagerly waiting for him with a warm towel and more suctioning

Over several minutes we gently suction out mucous from the nose and mouth

After we are sure the breathing passages are clear we stimulate him to breathe by gently rubbing him

Pup-eating

His mom is still in surgery, so we give him a quick meal until he can nurse. Nursing is important because the milk the mother produces contains antibodies he needs to prevent common diseases like Distemper. He cannot produce these antibodies just yet.

Pups-feeding

While our doctors are finishing the surgery our nursings staff goes to work making sure these puppies are fed and kept warm until the mother is fully recovered and able to nurse all of them


Whitepup-feeding

The nursing instinct is strong and the puppies greedily suck down the milk

Nurse assist feeeding puppy

Pups-resting

After nice meal all 3 of them take a well deserved nap


Mother-recovering

We let the mother recover completely before we let the pups nurse. She is exhausted from trying to get this last puppy out and needs some time to rest.


CSection-surgeons

Once mom was out of surgery and stable our surgeons could not resist, and had to hold the puppies

This was Dr. Wood’s first C-section, and she did a wonderful job! Next time she has to do one in the middle of the night she won’t need to call Dr. P or Dr. R to help her!

Here is a C-Section we did many years ago:

One of the most rewarding surgeries we perform is a Cesarean Section. Usually it is performed on small breed dogs because their pelvic canals are just too small to handle the size of the pups for a natural birth. This is the story of Margarita, a Chihuahua that had 4 large pups in her tank.

The gestation length in most domestic dogs is 63-65 days. When Margarita first came to us one week before she was due we knew a C-Section would be needed from her size and her radiograph.

How many pups do you see in Margarita’s abdomen? The answer to this question will become apparent later on.

On the appointed day Margarita was brought to our hospital for a C-Section by Dr. Palazzolo. On a dog that is this small, and has this many large puppies in its uterus, preanesthetic preparation is important. This consisted of a preanesthetic blood paneland intravenous fluids prior to and during surgery.

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

Surgery-Monitor

Once our surgeon has scrubbed up and is  in sterile gown, gloves, and mask, the surgery begins

_D2A8630

Here she is on the surgery table. You can see the green tape covering her IV catheter and if you look closely you might be able to tell that her abdomen has already been shaved. She has also been given a local anesthetic where her incision will be. All of these things are done prior to any anesthesia. They will allow us to use less anesthesia for the actual procedure which is important to minimize any anesthesia that depresses the pups.

At this point things start moving fast. Margarita has been given an IV sedative to relax her, the final surgical prep has been applied, and a breathing tube (called an endotracheal tube) is in her windpipe giving her 100% oxygen. Once she is intubated we move fast, and in the next 5 minutes all of the pups will be out of her uterus. While her anesthesia is being monitored the rest of the team is preparing to receive the pups.

She is draped and a rapid incision is made in her skin. By giving her the local anesthetic earlier she does not feel the skin incision and we can keep the anesthetic level to a minimum.

The uterus is rapidly located and gently squeezed out of her incision. We make the incision in her abdomen just big enough to gently exteriorize the uterus because she will heal faster and nurse her pups better with a smaller incision. This is where the experience of our surgeon, Dr. Palazzolo, comes into play.

This is one horn of the uterus and contains 2 of the pups. The other horn of the uterus can be visualized running horizontally at the bottom of the picture.

A scissors is used to cut into the uterus. Special care is taken not to cut the pups,which could be moving in the uterus.

The first pup is gently removed with his umbilical cord still attached.

You can get a better idea of the amniotic sac that completely covers the pups.

The first things our nurses do upon receiving the pups is to rub them gently yet vigorously in a towel. This stimulates them to breathe. They also gently shake them to remove fluid from their lungs.

The nurses use a special bulb syringe to suction fluids from pups that aren’t eliminating fluid from shaking and rubbing.

Any pup that is still not breathing well at this point is giving a drop of respiratory stimulant on the top of its tongue.

Once our nurses feel the pup is breathing on its own they tie its umbilical cord.

After all 4 pups are stable they are put under a heat lamp since at this early stage in their lives they do not have a very strong ability to regulate their body temperature.

Meanwhile back in surgery Dr. P is checking the abdomen to make sure there is no bleeding prior to suturing the abdomen. In Margarita’s case she was also spayed.

Her muscle layer is carefully sewn back together. These sutures are critical to prevent a hernia from occurring, especially when pups vigorously nurse.

With her skin sutures complete Margarita is now taken off the anesthetic machine and a pain injection is given to her.

Our nurses take care of the feeding while Margarita rests and recuperates. We won’t let 4 hungry pups nurse until she is strong enough.

Here are our 4 little piggies all in a row sleeping after their ordeal and their first meal. Their tummies are full and they are keeping each other warm.

In a surgery like this there needs to be close coordination between the surgeon, anesthetist, and nursing staff. You can see how much time and attention our nurses put into doting over these puppies.

Time for a little shut eye, we had a big day!

This is one of those pups several months later with her proud mom! Can you guess which of the above 4 puppies this one is? (Hint-look at the white spot on the forehead).

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Geriatric Medicine

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In the past, we may have accepted a declining quality of life for our aging pets as a fact of life beyond our control. Like humans, older dogs and cats are more likely to encounter health problems than younger pets. Thanks to advances in veterinary medicine, pets are living longer than ever before. A 7 year old dog or cat is equivalent to a 50 year old person.

Most humanoids are practicing preventive medicine at this age- routine physical exams, breast exams, prostate exams, blood pressure checkups, blood panels and dietary changes. Dogs and cats need similar preventive medicine at this age. Since they age approximately 7 years for every 1 year of human life, an 8 year old dog or cat is equivalent to a 56 year old person, and a 9 year old dog or cat is equivalent ot a 63 year old person. This rapid yearly increase in equivalent age emphasizes the fact that we need to pay close attention to all dogs and cats as they move beyond 7 years of life.

Just as older people experience a progressive decline in physical condition, so do senior pets. Studies indicate that 36% of senior dogs suffer from osteoarthritis, 18% show signs of Cognitive Dysfunction Syndrome, and the number one diagnosed disease of dogs in all age groups is dental disease.

Compared to humans, old age problems may progress up to 7 times faster in senior pets. Having your senior pet examined only once a year is like a senior person visiting the doctor only once every seven years. That is why, as your pet nears 7 years of age (5 years of age in Giant Breeds), preventive senior exams every 6 months can help assess your pet’s current health, provide a baseline for monitoring changes in the years ahead, and help detect health problems in the early stages, when diseases can be treated more effectively.

Senior Care is “geriatric” medicine for pets. Senior health care implies both preventive and therapeutic approaches to medicine, including nutrition, dental care, and exercise as well as therapy for diseases.

Age Chart

Relative age of Your Dog in “Human Years”
Age Dog’s size in pounds
years 0-20 21-50 51-90 90 +
5 36 37 40 42
6 40 42 45 49
7 44 47 50 56
8 48 51 55 64
9 52 56 61 71
10 56 60 66 78
11 60 65 72 86
12 64 69 77 93
13 68 74 82 101
14 72 78 88 108
15 76 83 93 115
16 80 87 99 123
17 84 92 104
18 88 96 109
19 92 101 115
20 96 105 120
= Senior
= Geriatric

 


Symptoms

Changes in behavior or appearance may be the first indication of a problem. However, these signs may not be apparent in the exam room during your veterinary visit. It is important for you to watch for subtle changes, especially in stoic older pets.

Signs of aging:

Difficulty climbing stairs

Difficulty jumping up

Increased stiffness or limping

Loss of housetraining

Increased thirst

Increased urination

Changes in activity level

Excessive panting

Circling/Repetitive movements

Confusion or disorientation

Excessive barking

Less interaction with family

Decreased responsiveness

Tremors or shaking

Skin and haircoat changes

Changes in sleeping patterns

Less enthusiastic greeting or behavior

Altered appetite

Weight change

Common Health Conditions of Senior Pets

Obesity- As their metabolism slows down it is easy to overfeed. This leads to arthritis, sugar diabetes, liver disease, and heart disease.

Dental– Inflammation of the teeth and gums may lead to pain, infection, tooth loss, bad breath, kidney and heart disease, and, as a result, decrease your pet’s life expectancy.

Hormone (endocrine)- cause a vast array of symptoms that are treatable and sometimes curable.

Cushing’s– Excess production of cortisol (cortisone) by the adrenal glands

Addison’s– The opposite of Cushing’s

Diabetes (sugar) – Excess glucose in the bloodstream due to a lack of insulin

Hyperthyroid– Excess production of thyroid hormone

Hypothyroid– Inadequate amount of thyroid production

Kidney– Failure of this organ can lead to chemical imbalances, anemia, compromised immune function, and blood clotting defects as well as altered mental capacity. Kidney disease is a leading cause of death in geriatric cats.Chronic Urinary Tract Infections can easily occur without you being aware. These are painful, and can predispose your pet to bladder stones.

Liver– Failure can lead to serious disease with chemical imbalances, anemia, compromised immune function, and blood clotting defects as well as altered mental capacity.

Heart– Pets with heart disease can experience difficulty breathing, fatigue, exercise intolerance, and lethargy.

Cancer– Can occur in many different organs. Early detection may improve the prognosis. Many treatments are available and most have few side effects.

Cognitive Dysfunction Syndrome– Similar to senility or Alzheimers in people.

Skin conditions-Hair loss, itching, and skin infections are common

Arthritis-This is painful and debilitating, and can easily sneak up on a pet without you being aware of it.

High Blood Pressure– Usually secondary to a heart problem, kidney problem, or high thyroid problem.

Inflammatory Bowe Disease (IBD)- A common problem in cats as they age.

Epilepsy– These seizures have an unknown origin, and occur in older pets.

Senior Exam

With frequent checkups, at least twice a year, we can screen for common senior diseases. By diagnosing and treating problems earlier, we may be able to slow the disease process and prevent pain and discomfort.

In addition to a complete physical examinationdiagnostic tests can help detect many diseases before your pet displays signs of a condition. Even if results are normal, the findings give you veterinarian a good baseline to identify and monitor changes in your pet’s health as the years progress.

You can do an in-home exam to help catch problems before they become entrenched.

Physical Examination We can check for physical signs of cancer, arthritis, heart and lung disease, dental disease, or cataracts.
Complete Blood Count
(CBC)
This test helps identify infections, anemia, and certain types of cancer as well as problems with bleeding and the immune system.
Serum Chemistry Profile This blood test can help identify diseases of the liver and kidney, and endocrine disorders such as Diabetes or Cushing’s.
Complete Urinalysis A urine sample can help test for kidney diseasediabetes, urinary tract infections, and bladder stones.
Fecal Exam A fecal sample can be checked for internal parasites and bacterial overgrowth.
Other Tests Depending on your pet’s overall health, we may recommend additional tests such as blood pressure measurementradiographselectrocardiography (ECG or EKG),ultrasound, thyroid (hyperthyroid or hypothyroid) or adrenal gland (Cushing’s or addison’s) testing, as well as liver, pancreas, and small intestine function tests.

Here are examples of blood panels and urine samples that caught problems early, and before they became so well entrenched we would have a difficult time treating them.

This pet is anemic

This one has kidney failure

This low Specific Gravity is a sign of a kidney problem 

Senior Nutritional Needs

Nutritional needs of pets change as they get older. Senior dogs should consume fewer calories due to decreased activity and reduced daily energy needs. This is very important because obesity increases the risk of serious diseases, arthritis, diabetes, cardiovascular disease, respiratory disease, and musculoskeletal disorders in older dogs.

Pet foods, specifically for seniors, are now available with fewer calories, limited phosphorous, more protein, balanced fatty acids, antioxidants, vitamins and minerals to meet the specific nutritional needs of senior pets. These foods have optimum amounts of nutrition, and can help in the progression of common diseases like kidney disease.

All cats that are 7 years of age and older should be on Hill’s K/D due to the significant prevalence of this problem.

Many older dogs are obese and arthritic, and the Hill’s food Metabolic and Mobility is a major help for them.

We have much more information about nutrition in animals, and why you should never take the advice of a pet store or groomer on nutrition. It is an interesting read.

 


References:

1. Survey of Veterinarians, 1998. Sponsored by The Iams Company and Pfizer Animal Health.

Developed for Long Beach animal Hospital, by Glenna M Gobar DVM, MPVM, MS, courtesy of Pfizer animal Health; Sept 2001

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Skin Conditions

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Some of the more common skin conditions we see in dogs and cats at the Long Beach Animal Hospital.

Allergic Dermatitis

Cushings (Hyperadrenocorticism)

Demodectic Mange

Hypothyroidism

Lick Granuloma

Ringworm

Sarcoptic Mange (Scabies)

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Dental Disease

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Dental disease is prevalent in almost every dog and cat we examine. This page has a large amount of information that will inform you of this serious and overlooked problem. Please set aside the time to fully understand it due to its importance regarding your pet’s quality of life.

Oral hygiene is one of the most overlooked areas of medical care for animals. Far too many pets come to us with advanced dental disease, requiring anesthesia, x-rays, and the removal of rotten and painful teeth. Some of these pets are systemically ill as the billions (yes billions) of bacteria in their mouths enter the bloodstream through diseased gums and serious infect important organs like the liver, kidney, and heart. As we increase our knowledge of animal health we realize that proper dental care does not just make your pet’s breath smell better; it is mandatory for your pet’s long term quality of life.

pddz5

We see too many pets presented in a state similar to this. The periodontal disease in this dog has progressed so far that it is systemically ill, and in danger of a spontaneous jaw fracture. Imagine how this dog feels!

Dental disease is a treatable and preventable problem, and since your pet cannot tell you how it feels, it is up to all of us, as members of your pet’s health care team, to address this problem. Most people wait too long to get their pets teeth cleaned professionally. Teeth cleaning should be considered a preventive measure, not a way to treat a problem that is already present. Good dental care revolves around the control of bacteria under the gumline where it is not visible. We will teach you how to prevent it and how to treat it.

Prevention is the key, so learn how to brush your pet’s teeth. If started at an early age this “bonding time” is an enjoyable time for all. When your pet is young, get it used to your hands around its mouth by petting it on the head and face gently, telling your pet how good he is in a soothing tone. Eventually get him used to your fingers being gently placed in his mouth and rubbing his gums. If you do it slowly and follow your pet’s reaction, you can make this a fun game for all. At the end of this page on dental disease there is more information on prevention.

When your puppy or kitten still has its baby teeth use our dental wipes to get your pet used to the procedure. By going slowly most puppies and kittens respond positively to the attention. You can dip a cotton-tipped applicator in tuna juice and use this to rub kitten gums.

Start brushing the teeth when the adult teeth are in, which is around 5 months of age. We can tell you when to start if you are not sure, and show you how to do it.

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Yes, you can brush your pet’s teeth, and yes, you can make it an enjoyable experience for both of you! Bring your pet in and we will show you how. If you start when your pet is young it will be much easier. This can be started when you do your puppy behavior training.

CET-pets

We have special dental kits for dogs and cats that make the process easier and more effective. They do not like the feel and taste of the toothpaste we use in our mouths, so do not use that. 

If brushing your pet’s teeth is not an option, we have a multitude of products to help replace brushing.  They are designed to aid in slowing down plaque buildup, which is the start of dental disease. They are not as effective as brushing, but are better than doing nothing.

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There is also a food called T/D (tartar diet) made by Hill’s which is a significant help in preventing dental disease. It comes in many different kibble sizes for different sized pets.We highly recommend it, especially for the small breed dogs that might be fussy about getting their teeth brushed.

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This food is unconditionally guaranteed, and can be returned for any reason

If you use some of these products, and have your pet’s teeth cleaned by us without anesthesia (it’s called non-anesthetic dental (NAD)), you will not encounter the serious and painful dental disease you will learn about later in this page. All of this needs to be started early in your pet’s life, and long before dental disease sets in.

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Having your pet’s teeth cleaned professionally, without anesthesia, is the best way to prevent dental disease. After they are cleaned this way you need to brush their teeth, until their next cleaning in 6 months. The effort is worth it, especially later in this page when you see  how bad dental disease can become. 

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The non-anesthetic professional teeth cleaning by Pet Dental Services is thorough, and the person that cleans your pet’s teeth will go over a report like this for your pet. 

The licensed technicians from Pet Dental Services will perform non anesthetic teeth cleaning at our hospital on the 4th Monday and Wednesday of every month. You can make an appointment and wait while it is being performed, or you can drop your pet off and pick it up later. If you wait it takes about 30 minutes.

All legitimate non anesthetic dental people are licensed by the state of California to perform this procedure. This can only be performed legally in the state of California under the direct supervision of a licensed veterinarian, which is why our doctors are present, and review any important dental findings with you after they professionally clean your pet’s teeth. This law is obvious for your pet’s protection.

Many unscrupulous people perform this procedure because they tell you they are saving you money and fooling you into thinking they are actuallly doing something medical for your pet, when they clean your pet’s teeth without the supervision of a veterinarian. This commonly happens at grooming shops and pet stores. They prey upon the irrational fear people have of anesthesia. In reality, since they are not making a correct diagnosis, or doing a thorough job, all they are doing is setting up the stage for the bacteria that is under your pets gumline to to wreak havoc later on, necessitating an anesthetic dental.

People sometimes wonder why pet’s need their teeth professionally cleaned by us, and then brushed by you, when they have memories of growing up with dogs and cats and never doing this. It doesn’t take much to answer this question. Pets nowadays eat diets that makes them prone to plaque. They also live longer, and just like in people, are more prone to disease as time goes on.

More importantly, we did not have the knowledge decades ago to understand how dogs and cats lived lives of chronic pain because we did not know, or could not diagnose, the periodontal disease that is occurring below the gum line. With the advent of digital radiography, and our current body of knowledge, we realize that we did not treat dental disease anywhere near as thoroughly as needed. This ignorance lead to poor quality (painful) and shortened lives for our pets.

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This is the crux of the problem. When you look at the teeth, and see some tartar, it doesn’t seem like much of a problem. Just scrape the tartar off and the teeth will look and feel better, and your pet’s breath will smell better. Job done right?

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Here is the same tooth as it is being removed while this pet is under anesthesia. The root on the right is rotten, compare it to the normal root on the left. We did not know this pet had a rotten and painful root until we probed it and took radiographs. If  this tooth had only been cleaned of tartar and not removed, this pet would have had a painful tooth indefinitely. 

We were able to detect this rotten root only because it showed up on our digital dental X-rays

This is a video of a different dog having its teeth cleaned under anesthesia. When our doctor examined the canine tooth it was found to be infected, with pus coming out of the gums. This would never had been found if we were not thorough and checking for this, and this dog would have had a painful mouth long term. Just as importantly, the large amount of bacteria that is entering the bloodstream on a chronic basis causes damage to the internal organs.

You can see the pus on the probe as it is moved around the base of the canine tooth

Cats get a unique dental problem, called neck lesions (also called FORL- Feline Odontoclastic Resportive Lesions), that are painful. When we encounter these problems we need to remove the bad tooth.

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What seems like just a red gum is actually the painful condition of the root called FORL

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Here is another example of a potential FORL lesion

The short video below is an example of how painful this is. This cat is completely anesthetized, yet when we gently touch  its premolar teeth with a probe, it moves its jaw in obvious pain.

It is the periodontal disease that is occurring out of sight and below the gum line that causes the most problem. This is the area we thoroughly need to address when we clean a pets teeth under anesthesia.

We take this problem seriously, and spend considerable time caring for pets with dental disease. Many dogs and cats are brought to us in advanced states of dental disease. Their teeth are infected and rotting out, and they have tremendous odor (severe halitosis) from the infection.  For animals that have such keen senses of smell, this chronic odor is very irritating. The stress on their internal organs due to the tremendous infections in their mouths can cause problems with the liver, kidneys, and heart valves.

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Dogs and cats with advanced dental disease need to be anesthetized, given a thorough oral exam, and have dental radiographs. They are closely monitored during the procedure, and all their dental problems are taken care of. This takes considerable time and effort on our staff as we carefully assess every tooth.

The following information on dental disease is very thorough. We have a summary page on dental disease if that suits your needs better.

Normal Tooth Anatomy & Development

The diagram above illustrates some of the structures of the normal tooth. It also shows Stage III periodontal disease, which you will learn more about later. On the left side you can see the bone of the jaw and the blue periodontal ligament. It is this ligament that keeps the tooth attached to the bone in the socket. You can also see the blood supply and nerves to the tooth. They are the vertical finger-like projections in the center of the tooth.

On the right side we have illustrated what happens in gum disease. The brown area between the tooth and gum is tartar and its associated bacteria. Tartar by itself is inert, and does not cause dental disease. Removing it makes the teeth look better, but it does not address the primary problem. It is the bacteria surrounding and within this tartar that we are after. Notice how a significant amount of tartar is below the gumline, and thus cannot be seen. Also, notice how the gum is pulled away from the tooth leaving a pocket.

As the bacteria progresses further down the tooth, the gum is pulled further and further away, the jawbone literally erodes away, and the periodontal ligament can no longer hold the tooth in the socket. The tooth is painful, rots out, or is removed when we professionally clean the teeth. The bacteria that eventually causes this erosion enters the bloodstream and can cause disease in other organs. It is this bacteria below the gumline that is causing all the trouble, and is the bacteria we remove when we professionally clean the teeth.

After the teeth have been professionally cleaned we can use non anesthetic dental from Pet Dental Services to prevent the problem from recurring. You are fooling yourself if you think you can take your pet to a groomer to have them scrape the tartar off once gingivitis is present. The teeth look nice, which means you have done something cosmetically nice for your pet, but you haven’t touched the medical problem.The teeth need to be cleaned by trained professionals from our hospital or Pet Dental Services, depending on the severity of the problem.

This radiograph of a tooth shows the same anatomy as above. We will show it again later when we show radiographs of diseased teeth. Notice how tightly the roots of the tooth fit into the healthy jaw bone. When we show you radiographs of diseased teeth later this jaw bone will be partially gone.

Dogs have 28 deciduous (temporary or baby) teeth and 42 permanent teeth. Anatomically they have 4 different types of teeth: Incisors (I), canines (C), premolars (Pm), and molars (M)

This is an x-ray of the lower jaw (mandible) of a dog. You can see how deep the roots go.

In comparison to dogs, cats have 26 deciduous teeth and 30 permanent teeth. They have the same types of teeth that dogs do, but in different proportions. They lack premolar #1 found in dogs due to a different evolutionary path.

The deciduous teeth start being replaced by the permanent teeth (in this picture they are the 2 large central incisors marked by the arrows) at 4 months of age. The puppy teeth that were there were probably swallowed.

Dogs seldom have problems with teething, although they do tend to chew things during this period. It is advisable to supply them with synthetic bones for this purpose, or else some of your personal items might get recycled! By 8 months of age all the permanent teeth have appeared.

Biofilms

Dental disease is all about bacteria. Due to the unique environment of the mouth, we measure mouth bacteria counts in the billions! Bacteria that adhere to the enamel of teeth colonize and begin synthesizing molecules, the most important of which are carbohydrates. These carbohydrates are sticky and act as a glue to attract more molecules on the teeth, eventually forming plaque. As time goes on calcium carbonate deposits on the plaque, hardens, and then becomes calculus. This is the hard material deposited on teeth people sometimes call tartar.

Cat-gingivitis

This is tartar (plaque) on the teeth of a cat. If we get on top of this plaque now, by cleaning this tooth professionally with non-anesthetic dentistry, and use the prevention measure discussed earlier, we can prevent it from getting gingivitis, and all its associated problems. 

Tartar is made up of calcium salts, food debris, bacteria and other organic matter. It is orange to brownish in color and although soft when deposited, it quickly hardens. It collects primarily on the cheek (buccal) side of the premolars and molars, although it can occur in any tooth.

Periodontal disease results when the bacteria at the center of this plaque move under the gumline. There are many different bacteria in the mouth that start the process of plaque development. Some are aerobic, and live off the rich oxygen supply in the mouth (can you guess why the mouth has a rich oxygen supply?). As mentioned above, some of the bacteria in the plaque that migrate under the gumline go to an area of no oxygen, and are called anaerobic. The anaerobic ones tend to cause the most problem. Here is a list of some of their scientific names (warning-they are tongue twisters, so you better brush up on your Latin):

Actinobacillus actinomycetemcomitans

Bacteroides asaccharolyticus

Fusobacterium nucleatum

Eikenella corrodans

Porphyromonas gingivalis

Actinomyces viscous

These anaerobic bacteria cause an inflammatory reaction, and break down the periodontal ligament. The end result; the tooth rots out. Also, as these bacteria invade deeper into the tooth cavity they reach the blood supply to the tooth, and can enter the bloodstream where they cause significant damage to the liver, kidney, and heart. It can even predispose pets to diabetes mellitus (sugar diabetes). The problem does not end there when it comes to periodontal disease. It can also lead to spontaneous jaw fractures, deep seated bone infection, and cancer (neoplasia) at the affected tooth.

Since bacteria are the main culprit in periodontal disease, it makes sense that antibiotics will be used to treat the problem. The two main ones we use are Clavamox and Antirobe. In select cases, where it is impossible to clean the teeth professionally, we will sometimes use one of these antibiotics in what is called pulse therapy. They are given for one week each month indefinitely. They are reserved for cases where the heart or other internal organs are seriously diseased and unable to withstand the sedation needed for professional teeth cleaning. Antibiotics are certainly no replacement for professional cleaning, but have a place in some select cases to help minimize the bacterial load and the halitosis.

How do you prevent these bacteria from starting the problem all over again after the teeth are professionally cleaned? Use the preventive care products mentioned at the beginning of this page, and get your pet’s cleaned professionally without anesthesia (non-anesthetic dental) every 6 months.

Symptoms

Symptoms of dental disease can range from subtle to extreme. One of the most common symptoms is bad breath (halitosis). Sometimes a pet with dental disease will cry in pain when you touch it anywhere near its muzzle. Another symptom is a partial or complete inability to eat (anorexia). A pet that has this problem may eagerly go to the food bowl, and either just look at the food or drop the food out of its mouth after only a few bites. Other pets might drool from one or both sides of the mouth, or paw at the mouth. Unfortunately, many pets are stoic (do not show outwards signs of pain when it exists on the inside), and do not show any symptoms until the problem is well entrenched, and the roots are rotting and painful.

The important point to remember is the fact that once you notice any of these symptoms, your pet’s dental disease is already causing discomfort or pain, and even affecting other body organs. Therefore, it is important for you to be aware of the existence of this problem, to learn how to perform a basic oral exam at home, learn how to brush its teeth,  and to bring your pet in for regular (every 6 months) dental exams by one of our veterinarians. An exam every 6 months might seem like a lot to some people. Compared to the typical lifespan of a dog or cat, it is not very frequent. Your pet cannot tell you its mouth hurts, it is up to us, as a team, to ensure that this inevitable problem is properly monitored and treated before it causes discomfort and pain, and sometimes premature organ failure.

Stages of Gum Disease

Nature has a beautiful design with our teeth. The enamel on teeth is the hardest organ in the body, and it adheres to one of the most sensitive parts of the body, the gums.

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The close up shot of the gums of this normal dog are how healthy gums should look. Look at the detail of the gingiva (where the gums meet the tooth), and how adhered the gingiva is to the tooth.

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This is a healthy canine tooth with healthy gums

Stages of Periodontal Disease

There are 4 stages of periodontal disease. The first stage occurs when bacteria cause an invisible film of plaque to form on the teeth. The bacteria react with minerals and other debris that accumulate in the oral cavity, eventually causing tartar. You learned about his already in the biofilms section.

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This lower canine tooth has tartar and gingivitis, as evidenced by the inflamed gum at the base of the tooth. This means bacteria are already causing trouble below the gum line

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As the gingivitis and periodontal disease continues,  the underlying gum is pulled further away from the tooth.  The pocket of bacteria under the gumline in this tooth is significantly weakening the periodontal ligament and weakening the bone of the jaw.

Left untreated, the teeth eventually progresse to Stage IV periodontal disease. This tooth shows advanced periodontal disease as evidenced by the ulcerated gums (blue arrow), pus along the gum line, and severe tartar. When this happens your pet will experience pain and might be internally ill from the bacteria spreading to internal organs via the bloodstream. Pet’s with this problem are in jeopardy of internal organ failure.

Here is another dog with a similar problem. The tartar is so thick that it is literally holding the teeth in place! Notice how far up the inflamed gums are. In Stage IV periodontal disease the tartar can be so extensive that it is the only thing holding the teeth in the socket in some cases. When we remove the tartar the teeth literally fall out.  Its hard to believe that someone would let their dogs teeth progress this far. Unfortunately, this is not an uncommon situation.

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Some dogs that chew on their skin due to allergies will get the hair wrapped around their teeth and erode the gums

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When we remove the hair the roots of the teeth are exposed due to the erosive nature of the hair on the gums.

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The arrows point to the exposed roots. This is painful, and the teeth need to be removed.

In some cases the infection under the gumline has eroded away the gum tissue that normally covers the root. If the tooth has 2 roots it will cause a hole to appear between the roots where the gum has eroded- this is called a furcation lesion.

This is one potential outcome when pets with periodontal disease are not treated. The teeth in this cat literally rotted out of its mouth. This situation is completely preventable. Fortunately, pets that have no teeth can still eat well, but that is small consolation for this cat. The years of chronic bacteria that were released into this cats bloodstream when the periodontal disease progressed from Stage I to Stage IV can seriously affect the internal organs and cause this cat to have premature organ failure.

This is another potential outcome for a pet that has periodontal disease. This dog’s lower jaw (mandible) is fractured at the chin because of long term periodontal disease. There are only two incisor teeth left. A wire needs to be put in to hold this jaw together. 

This is what the jaw looks like on a dog with healthy teeth

This is how we wire a jaw together so a pet has no pain and can eat. It is wrapped all the way around the jaw and anchored under the chin. It will need to stay in place at least one month.

The left arrow points to the wire on this radiograph . The large right arrow points to the diseased mandible where we removed rotten teeth. 

There are other serious complications that can occur when proper oral hygiene is neglected. This dog had a seriously infected tooth that created a fistula (arrow) into its upper jaw. Food will go into the passage and end up in the nasal cavity, which is not a place where food belongs. This dog will have chronic infections because of this, which can even lead to life-threatening pneumonia.

Heart Problems Secondary to Periodontal Disease

The heart is one of the internal organs that can be affected in advanced dental disease, because bacteria from the mouth infection can readily deposit on the heart valves (especially the mitral valve). Our heart page has extensive information if you would like to learn more.

This picture is from our heart page. The top arrow points to a normal valve leaflet. The bottom arrow points to a thickened valve leaflet, which could be the result of chronic bacteria from the mouth. The thickened and rounded lower leaflet causes the problem.

The thickened valve can malfunction and leak blood backwards through one of the chambers of the heart, instead of forward like intended. This turbulence of blood as it flows through this leaky valve can often be heard as a heart murmur. The potential result of this back pressure is congestive heart failure- a buildup of fluid in the lungs (pulmonary edema). Fluid in the lungs will cause your pet to start coughing and feel very ill- it is a serious sign that requires immediate veterinary care.

In addition to heart (cardiac) problems, dental disease can affect the kidneys and the liver. These are both vital organs, and require a pet free from dental problems if they are to function properly. Some pets do not live a full life due to the chronic affect the bacteria has on their internal organs, leading to premature organ disease.

Diagnosis

As with any illness, the diagnostic process is carefully followed so that a correct diagnosis is made, and other problems that are a result of the dental disease (ex-heart murmur), or are occurring simultaneously (ex-kidney disease), are not overlooked. Since there are numerous diseases and conditions that can mimic dental disease, the diagnosis of dental disease must be performed by a veterinarian.

During a routine physical exam we will be be performing a complete examination, including the oral cavity. If dental disease is present, it is during this exam that we determine if your pet needs an anesthetic professional cleaning or a non-anesthetic professional cleaning. We can only perform a complete oral exam, looking at the tonsils, tongue, and back of the mouth, when your pet is anesthetized. This allows us to find oral foreign bodies, stomatitis, and cancers of the mouth, that we cannot see when your pet is awake.

Oral-exam-stomatitis

We never would have diagnosed the severe stomatitis in the back of this cat’s mouth without an oral exam under anesthesia. This is a painful condition and not a diagnosis that should be delayed. 

A complete oral exam is also performed during non-anesthetic dentals.  Due to the thorough nature of the non-anesthetic professional cleaning, we sometimes find problems that require an anesthetic professional cleaning.

We will also show you how to perform a basic oral exam so that you can monitor your pet’s progress at home. The oral exam is not complete until we exam your pets mouth (the medical term for the mouth is oropharynx) under anesthesia. Only then can we check for tumors, ulcers, gum disease, foreign bodies, and infections, and enlarged tonsils.

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A basic oral exam, which you can do at home, would have found this tumor on the gums long before it got this large

Pre-anesthetic Preparation

The first step in the process is yearly exams by one of our doctors, and more often if there is a medical problem of any kind or you pet is on chronic medication. Many people will have this yearly exam performed when their pet comes in for yearly vaccines. We will look inside the mouth and determine if any oral disease is present. If there is enough gum disease to warrant professional cleaning, pre-anesthetic tests will be ordered. We will also try to identify teeth that might need removal if there is an obvious problem.

For pets under 5 years of age a routine in-house blood panel will suffice in most cases. For older pets, or those with other problems, a more thorough blood panel will be ordered. These blood panels will let us know if your pet is ready for anesthesia, will check your pets health in general, and will allow us to assess any damage to the liver or kidneys from the chronic bacteria in the bloodstream. In addition, our doctors will sometimes recommend other tests prior to anesthesia. These tests commonly include radiographs of the lungs or abdomen, along with an electrocardiogram to assess the heart.

Our pre anesthetic diagnostic tests page covers these tests in more detail. Our doctor will analyze the results of the pre-anesthetic diagnostics tests and customize an anesthetic protocol for your pet. In many cases Intravenous fluids will be given prior to and during the professional cleaning. These fluids, when used in combination with pre-anesthetic tests, dramatically minimize the risk of anesthesia. as a final preparation prior to professional teeth cleaning one of our doctors might put your pet on antibiotics.

Anesthesia

When significant gingivitis is present proper dental care involves more than just scraping tartar off the teeth. Just scraping the tartar may temporarily make the teeth look better, but it is not addressing the real problem that occurs under the gumline. Thorough dental care involves scaling, probing, radiographing, flushing, measuring, fluoride and polishing. You will learn more about these in the next section. These treatments can only be accomplished on an anesthetized pet. It is not realistic to think that all of this can be accomplished on an awake pet, and be as thorough as we can on an anesthetized pet.

When these procedures are performed properly we can reverse the periodontal disease in some cases, and keep the teeth and gums healthier for a longer period of time. Since the risk of anesthesia is negligible with the precautions we take and the precise method available to administer and monitor anesthetic, it is well worth the negligible risk in order to clean the teeth and gums properly. In reality, the risk of disease occurring by not cleaning your pet’s teeth professionally is greater than the risk of anesthesia.

We have extensive experience in anesthetizing pets, especially the geriatric pets that so commonly have advanced dental disease. To minimize any anxiety you have over anesthetizing your pet, one of our doctors will personally discuss our anesthetic protocol with you and set up an anesthetic plan that is specific for your pet’s condition. Our anesthesia page has extensive detail on how we anesthetize animals.

Surgery-Monitor

We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

Professional Cleaning

This cleaning has four main components:

  1. Cleaning above the gum line with the ultrasonic scaler
  2. Cleaning under the gum line with special instruments
  3. Probing and examining of each tooth, with dental radiographs, to look for root decay and loss of bone
  4. Removal of rotten teeth
  5. Deep cleaning under the gum line with a curette, called root planing, to get at the bacteria and plaque in deep pockets
  6. Placing antibiotics on teeth with deep pockets in order to save them
  7. Antimicrobial medication to control the periodontal disease
  8. Oral sealants to prevent plaque buildup and the recurrence of the problem

Every pet is different, and we might do some or all of these procedures.

Oral Exam and Charting

The first aspect of the cleaning process is an examination of the complete oral cavity. It is only when a pet is sedated can this be completed thoroughly.

The arrow is pointing to a cyst in the mouth of this dog that was not seen until it was sedated. The owner did not know it was present, nor did this dog show any symptoms. We were able to remove it before it became a problem.

After our thorough oral exam we chart the problems encountered

Dental Unit

The equipment you will find in our hospital is the most advanced available. It allows us to provide a wide array of dental services.

We use a specialized ultrasonic scaler that is made for animal teeth

Radiology

Radiography is an important part of dental care and is commonly performed as the next step after the oral exam. During your pet’s oral exam under anesthesia our staff will measure the depth of the pocket on the teeth that have disease. If the depth is 4 mm or greater we might take a radiograph of the tooth to make sure the underlying jawbone and root are healthy. If the root or jawbone are not healthy the tooth needs to be removed or a root canal at a specialist needs to be performed.

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If there is a large pocket or bleeding occurs when we probe the tooth, we will radiograph it to see the roots

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Our dental x-ray machine is made specifically to radiograph animals

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The machine is automated, allowing us to rapidly take high quality radiographs

The high definition of these radiographs allows us to see problems that are not apparent during the oral exam. Here is the normal tooth radiograph you saw at the beginning of this page.

This radiograph shows a problem around the root. Do you see the dark, semicircular area around the root of the tooth in the very center of the picture? Compare it to the other root of this same tooth just to its right. This dark semicircular area radiographically is called lucency, and is an indication of deep seated infection in the tooth. It is painful and needs removing.

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In this radiograph the jaw bone has been eroded down to expose parts of the roots on both teeth. This is the furcation lesion shown earlier.

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Do you see the damage to the two teeth at the top right of this radiograph ?

Calculus Removal above and Below the Gumline

If the tartar is extensive, as it is with this dog, a special dental instrument is used to crack off large pieces of tartar before we use the scaler.

This enables us to clean the teeth faster, another method to minimize anesthetic time. It also reduces wear on the ultrasonic scaler tip.

Scaling teeth is greatly facilitated by a special instrument called an ultrasonic scaler, which you learned about earlier in this page. By vibrating tartar off the teeth with the scaler we cause minimal trauma to the tooth enamel. In addition, the rapid manner in which it removes the tartar minimizes anesthetic time. The gentle nature of the scaler allows us to clean under the gumline and not irritate the gums.

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The tip vibrates 18,000 times per second, and literally vibrates tartar off the teeth. It does not harm the enamel, and lets us clean the teeth faster than doing it by hand. It continually sprays water to minimize heat buildup which could irritate the gums.

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It has a special light to give us good visualization so we do not miss anything or harm the gums

Probing and Measuring

Here is a close-up of the probe. Each of the notches is 1 mm, the total length being 10 mm. Anything more than a 3 mm pocket under the gums in dogs, and 0.5 mm in cats, is significant.

Lets have a little fun and show you just how small 10 mm is, courtesy of Uncle Abe

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When we measured the depth of the pocket on this tooth it was obvious from the bleeding and the depth of the probe that periodontal disease is present and a radiograph is needed

If we think the bone loss seen on the radiograph is manageable, and the gum pocket is not too large, we can place a long acting local antibiotic, called Clindoral®, under the gumline. This will continually kill the bacteria causing the gingivitis. The ultimate goal is to save the tooth from advanced periodontal disease and the need to remove a rotten tooth. If the problem is too advanced for this treatment, we will remove the tooth.

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It contains an antibiotic called Clindamycin

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It comes in a prepackaged syringe

Dentistry-Gel

It allows for precision placement of this antibiotic under the gums, with the long term goal of saving the tooth

In some pets the tooth problem is so severe that removal of the tooth is necessary. We make this determination only after probing, taking a radiograph, and exploring the option of using Doxirobe or Clindoral

Dentistry-NerveBlock

Before we extract a tooth we use a short acting and long acting local anesthetic, in addition to the general anesthetic currently being used. 

After removal of a tooth we suture the gums over the opening for faster healing, and to prevent food particles from going in the socket.

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This is the opening that remained after removing a severely infected canine tooth in this cat. The gums are hardened and the opening cannot be sutured closed. 

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If the opening cannot be sutured, we pack the opening with a special bone graft

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This is the opening with the bone graft in place

Root Planing

For the remaining teeth, root planing is probably the most critical step in the professional cleaning proces. By scraping the bacteria under the gumline with this special instrument we take care of the problem at its core. This can only be done on your pet when it is under anesthesia.

We use a specially designed instrument that is gentle yet thorough

periodontal-disease-root-planing

Root planing allows us to get at those bacteria under the gum line

Flushing the Gums

After the teeth are scaled and probed, and the roots have been planed to remove the originating bacterial cause, we spray them with chlorhexidine to further help eliminate the bacteria that are causing gingivitis. It is only after this point in the professional cleaning process that we have significantly decreased those billions of bacteria.

This special antibacterial reduces the bacteria burden in the mouth

Polishing

Polishing the teeth makes them look whiter. It also smoothes off the enamel surface and makes it more difficult for bacteria to adhere. Once bacteria get reestablished, the cycle of plaque leading to tartar and eventually gingivitis gets started all over again.

Dentistry-teeth-scaling-21

The teeth are polished with the same instruments dentists use on us

Fluoride Treatment

One of the final steps in the cleaning process is the application of fluoride to prevent cavities. We bathe the teeth in fluoride for a few minutes, then rinse it off. It has a very nice smell, too bad we can’t transmit smells over the Internet. We even put fluoride on the teeth of pets when they are spayed or neutered to help protect their teeth when they get older.

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It smells good and is fun to watch as it foams up and covers the teeth

If the enamel on your pet needs a sealant, we use Oravet. It significantly reduces plaque and tartar formation by creating an invisible barrier that helps prevent bacteria from attaching to your pet’s teeth.

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Prevention

Just like in people, routine preventive care is critical to proper dental hygiene. This was discussed at the very beginning of this page. This saves your pet from extended periods of pain and unnecessary tooth loss, and can save you the expense of the veterinary care needed to treat advanced dental disease. Your pet’s teeth should be checked every 6-12 months by one of our doctors, especially if it has already had gingivitis and had its teeth cleaned. Any pet that has had periodontal disease should be checked every 3 months. One of these check ups can be accomplished when your pet is brought to our hospital for yearly booster vaccinations.

One of the most important things you can do to slow down the recurrence of dental disease is to brush your pets teeth. This will help keep the gums healthy and prevent tartar buildup on the teeth on the cheek side (buccal) of the mouth, although it does not work as well on the teeth on the tongue (lingual) side of the mouth. Even though this may sound like an impossible feat for an uncooperative pet, it is one of the best ways to prevent dental disease. Even though the teeth will eventually need professional cleaning again in the future (most people get their teeth cleaned several times per year), proper brushing will decrease the amount of dental disease that occurs and the number of times we will have to clean your pet’s teeth over its lifetime.

Due to the short life span of pets in relation to people, proper home care of your pet’s teeth becomes an important health measure. When brushing the teeth there are some common sense things to do to make the process go smoother. One of our technicians will demonstrate some of these techniques with one of our hospital cats (they love the attention). It is important to remain calm and patient, since for most pets having something put into their mouths is a new experience. With a little tincture of time, the procedure progresses smoothly. also, it is highly advantageous to start the brushing process at an early age.

Patience is the key! Try to do something positive (feeding it, playing or walking)  with your pet just after brushing to condition the behavior for the future. Try to make the whole process fun, and don’t ever let on that you are doing something good for your pet (kinda like child psychology- if its good for them they won’t do it). With your pet near you or on your lap, maybe while watching TV, let your pet get used to your finger near its mouth. Dipping your finger into a food or liquid your pet has acquired a taste for helps start the process smoothly. When it is comfortable with your finger, use a soft gauze to massage the gums and gently rub the teeth. a cotton tipped applicator can also be used. Eventually you want to progress to a toothbrush.

In smaller pets, especially cats, proper restraint is important. There needs to be a proper balance between too little and too much restraint, a balance that varies with each pet. This is especially true with cats. For smaller pets, placing them on a table will make the process go smoother. Larger pets can also be placed on a table, if feasible, or can be restrained on the ground. Only one or two people should be involved in the cleaning process, usually without children present. We have a complete page demonstrating this restraint technique.

Eventually, introduce a soft bristled toothbrush. These toothbrushes are available in our dental kits. A rubber finger brush can be used but a toothbrush is preferred. You should not use your personal toothpaste to brush your pet’s teeth because the taste can upset their stomachs. Our dental kit has toothpaste that is specially made to be palatable to animals. These kits also have suggestions to make it easier to brush your pets teeth.

If you consider daily tooth brushing a chance to enhance your bond with your pet, you and your pet will find it more enjoyable. Brush the teeth in a slow and circular motion with a small amount of toothpaste. Its important to brush the outside of the teeth (the teeth up  against the lips and not the teeth up against the tongue) since that is where the plaque is most prevalent. If your pet is cooperative brush the insides next. Your goal is to brush at least 3 times per week. This will decrease plaque by 90%.

If you encounter resistance on a pet that normally lets you brush, or see blood or there are blood tinges on the toothbrush, smell any odor, see any inflamed area or swelling, or a buildup of tartar or inflamed gums, you should bring your pet in for an exam. If the tartar is significant it is time for a professional cleaning.

In some cases brushing is just not feasible. In these situations you can use the dental treatments recommended at the beginning of this page.

Congenital Abnormalities

Small breed dogs tend to have dental problems more often than large breed dogs. This may be due to the fact that they have smaller oral cavities and the teeth are forced closer together. Cats get comparatively few congenital problems regarding their teeth. Any condition where the teeth are not normally positioned is called a malocclusion.

Malocclusions are corrected only if there is a problem with mastication (chewing). Undershot jaw (lower jaw protrudes beyond the upper jaw) is seen on occasion, and is prevalent in small dogs and in breeds like Bulldogs, Shih Tzu’s, and Lhasa apso’s. Overshot jaw (upper jaw protrudes beyond lower jaw) is similar to buck teeth in people.

Occasionally, a dog will not shed a deciduous tooth when a permanent tooth starts to come through the gums in the same location. These retained deciduous teeth, along with any extra teeth, should be removed because they will result in displacement of the permanent teeth. Problems of this nature are discovered by our doctors on routine exams. This enforces the importance of bringing in young pets for vaccines and exams at an early age.

Miscellaneous Dental Problems

Carnaissal Tooth abscess

The carnaissal tooth (upper 4th premolar) may become infected and result in the formation of an abscess around the root. This is a very painful condition and is often accompanied by fever, loss of appetite and depression. a classic symptom of the problem is discharge through the face below the eye. This tooth needs to be removedfor the problem to be corrected. It has a deep root and needs careful extraction to correct the problem.

Lymphoplasmocytic Gingivitis

This disease, seen almost exclusively in cats, is a specific inflammation of the the gum tissue. It is a painful and debilitating condition that is controlled but not cured. It is treated in various ways, including surgery with a laser.

Cracked Teeth

It is very common for pets, especially dogs, to break or loosen their teeth while playing or chewing. This can cause significant discomfort and predispose your pet to dental problems later on in life. Injured teeth are usually removed, under general anesthesia, to ensure that the whole tooth is removed, including the root. If the root is not removed there will be a continual problem. In some cases we will refer you to a specialist that will determine if the tooth can be saved.

This dog fractured its tooth by chewing rocks

It was so badly traumatized it had to be removed to prevent pain and infection going into the root of this tooth. This tooth has 2 deep and strong roots, so it has to be split in half with a high speed drill.

The tooth just after removal

Cavities (caries)

Due to the nature of their enamel, dogs and cats do not routinely develop cavities. If they do, the cavity looks like a black area on the tooth, usually seen at the gum line or on top of the molars. Cavities can lead to pain and difficulty in chewing. The usual treatment is extraction of the tooth, although we can refer you and your pet to a specialist in veterinary dentistry to fill the cavity and save the tooth.

Discolored Teeth

Discolored teeth are seen in some pets. This can be caused by diseases like Distemper, the administration of certain antibiotics during the first few months of life, or trauma. If you notice discolored teeth please bring your pet in for an exam to determine the cause of the problem and if treatment should be instituted. Teeth that are red stained or red tinged have internal bleeding and need dental care.Antibiotics like tetracycline, if used when your pet is young, can stain the teeth permanently

Worn Down Teeth

Worn down teeth are usually caused be chewing rocks, chains, and fences. This is a behavioral problem that should be corrected to prevent long term problems. also, dogs that continually chew or bite at the skin due to allergies or fleas will cause the incisor teeth to be worn down, sometimes all the way to the gum line.

This problem can be detected during a routine exam and corrected by prevention of chewing on itchy skin before the teeth get worn down too far

At this stage there is no way to correct the problem without extensive dental work with a specialist

Growths

Pets can get growths in the oral cavity, some of them can be benign, some malignant. Any growth or inflamed area in the mouth should be biopsied.

A benign gum growth that occurs usually in older dogs is called an epulis. The growth of the gum sometimes become so large that it covers a tooth almost completely.

This is the same growth as above 1 week after removal using the laser

What is the next step?

If one of our doctors feels your pet needs to have its teeth professionally cleaned there are several steps you should take:

  1. Make an appointment to have the teeth cleaned before you leave our office. This will give you greater flexibility in your scheduling and allow us to accommodate you as much as possible. One of our receptionist’s will give you a written price estimate based on the doctor’s written instructions.  An estimate will be given that covers all anticipated costs. Even though our estimates are very accurate, there may be slightly greater, and more often lesser, charges on the final bill. This might be because some teeth need removal or medication needs to be sent home, or even finding something on the oral exam while under anesthesia that was not readily visualized during the initial exam. If there is any significant change in the price we will call you before proceeding. Please leave a phone number where you can be reached.
  2. If one of our doctors feels your pet needs pre anesthetic diagnostic tests, have them obtained while you are here, or drop your pet off and return to pick it up later when the tests are complete. Any test samples sent out to our outside laboratory will be available the following morning. Please call our office after 10 AM the next day for these test results.
  3. The night before the teeth cleaning take away all food and water before you go to bed, and make sure your pet does not eat anything in the morning. Our office opens up at 7:30 AM for drop offs. We appreciate having your pet in for its teeth cleaning by 8 AM.
  4. We will anesthetize your pet and clean its teeth sometime in the morning or early afternoon. One of our doctors will call you as soon as the procedure is complete.  It is very rare for a pet not to go home on the same day its teeth are cleaned. Your doctor will let you know if he plans on keeping your pet overnight. This might be because your pet is older or has a medical problem that requires us to monitor its progress in the hospital for an additional night. The best time to pick up your pet is in the late afternoon or early evening.  We are open until midnight every night for your convenience.You will be given written post dental instructions when you pick up your pet. If you have any questions after reading these instructions please let us know. Your pet may be groggy the first night. This is not because of the anesthesia, it is because of the pain injection many pets are given after their professional cleaning.
  5. Contact with children and other pets should be supervised by an adult the first night. Give it a small amount of water and soft food an hour after getting home. If it eats and there is no vomiting, give it some more food and water. It might experience some grogginess that evening because of the pain shot we give (some people welcome this, especially with young and active pets), but should be back to normal by the next morning. Please call us the next morning if you have any questions or you feel there is a problem (ex.-not eating, very lethargic).
  6. If we send your pet home with pain medication or antibiotics use them exactly as prescribed.
  7. Call us if your pet does not resume its normal activity and eating habits within 24 hours.
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