Monday, January 23, 2012

838. The case of the teeth chattering Chihuahua - follow up

The teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
DRAFT


HOOK
Teeth chattering in dogs. AUDIO CLIP
Image of THE CHIHUAHUA


Snow fall --- cold winter, snow-storm, but this is sunny Singapore
Antagonist arriving? Big bear attack when walked near the forest?
Loud noise --- fall from the sky, a meteor, earthquake tremors - 6th sense
A dog catcher on the prowl with his net? Downhill wind scent
A female dog nearby? Scent

INTRODUCTION
the case of the teeth-chattering Chihuahua
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
24 January, 2012

What causes it? The owner with the 8-year-old Chihuahua was a fair young lady probably had done her internet research and one of the websites would be:
http://answers.yahoo.com/question/index?qid=20100126080555AAfbVSv


AN EDUCATION VIDEO FOR VET STUDENTS AND PET OWNERS
COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Singapore, Jan 24, 2012

MIDDLE

CAUSES OF TEETH CHATTERING

1. Behaviour? Nervous, excitement. (Video clip of chattering). Not for her dog as this teeth chattering was recent and her dog was a calm and cool canine since young. When I saw her, the Chihuahua never chattered his teeth! Cool as a cucumber, the older Englishman would say. The google generation like this owner would say: "So cool!"

2.Cold freezing weather? (Slide of winter, snow fall)
Not in Singapore. It is Summer season all year round.

3. Certain breeds suffer from nervous disorder e.g. seizures, neuronal degeneration in young Cocker Spaniels or other breeds, white dog shaker syndrome in white dog breeds such as West Highland white terriers, the Maltese and the Bichon Frise. This needs early veterinary consultation.

4. Dental pain? This would be the likely cause as the old dog had bad breath, gum infections and loose decayed teeth. So she brought her dog to her vet as she felt that the recent teeth chattering could be due to toothache. Her vet wanted her to sign an anaesthetic risk consent form and forewarned her that her dog was an older dog and might die on the operating table during dental work.

CASE OF THE TEETH-CHATTERING CHIHUAHUA
FIRST VISIT
Sunday, January 15, 2012
The young couple came with the Chihuahua after having consulted a vet earlier. Death on the operating table is the main concern with the fair lady. Vet 1 had insisted that they sign the anaesthetic consent form highlighting the risk of death in an old dog undergoing dental work. "This is the common practice," I explained. "Even the human hospitals will ask you to sign the form if you go for anaesthesia and surgery. In the Singapore General Hospital, I was even given a 10-minute talk on anaesthetic risk by a young doctor in a room as I was scheduled for surgery the next week."

Her biggest worry and that of her mum was anaesthetic death. The vet must listen to what the client has to say. How competent is the vet? She does not know.

"How many anaesthetic deaths have you encountered when you did dental scaling?" she asked my associate vet who was handling the examination together with me. This was the sort of question many internet websites have advised the dog owner to ask the doctor. My associate vet said: "I refer you to Dr Sing."
The young lady turned her head to me for an instant reply.

I said: "I can only speak for myself. In my over 30 years of dental scaling, I have not encountered any anaesthetic death. This is because dental scaling and work do not require long anaesthesia. Therefore the risk of deaths on the operating table is very low. The anaesthesia should be completed within 15 minutes. Careful monitoring of the vital signs by the vet is most important."

I don't permit idle chatter during dental surgery. Nor do I make small talk with my assistant during surgeries. A singular focus on the surgery. Speed accuracy and completeness.


"Look at the right face," I pointed to the facial swelling. "Do you see a big swelling below the eye? The bacteria from the root of the back teeth, the 4th premolar, had gone into the face, causing this swelling. It is called a malar abscess."

The lady had a second look at the right face. "Compare to the left area below the eye," I suggested. "There is no swelling there!"

The lady turned her head to inspect the left face. This new finding added to her worries. She knew a dental work under general anaesthesia was necessary. Dental gels and paste that claim to work would not be effective. The internet advertisements of pet teeth are products are many.

Warnings of high anaesthetic risks and death esp. for the older dogs flashed back into her mind. She was well educated and informed to know that such products would not work for her dog.


ALTERNATIVE TREATMENTS WITHOUT ANAESTHESIA
1. Oral care gels and paste, chew toys and kibbles?
2. No anaesthesia dog groomers. Need to hold the dog firmly and rigorously to do the scaling or extraction as most dogs fight against such dental work without sedation and are frightened of it.

3. No action from the owner. Leads to oro-nasal fistula as in another Chihuahua. Show clips from
1. Chihuahua with a non-healing facial wound - oro-nasal fistula
http://www.youtube.com/watch?v=5AWHpWYWgy4&lr=1
2. Follow up on the Chihuahua after surgery and pyometra death
http://www.youtube.com/watch?v=ExTT2a8eUCs


How about dog groomers offering dental scaling without anaesthesia? There are such services offered by some pet shops in Singapore. This was an educated owner in my assessment, probably having completed higher education level and knows the situation.

She had done her internet research and knew that her dog would need more than dental scaling. He needed to have his loose and decayed teeth extracted. And this could not be done by the dog groomer without anaesthesia.

Her vet insisted that she signed the anaesthetic form first as taught by their veterinary professors to cover their back in case of litigation.

Here, at Toa Payoh Vets, my vets do insist on the client signing the anaesthetic form too. For me, I don't insist on it after explaining in detail one-to-one the risks and benefits thoroughly. So, I seldom get the owner to sign the form as this cause considerable stress for some of the young ones over my past 40 years of practice. If the client has no confidence in me, I would suggest going to another vet.

For this case, I advised antibiotics for the next few days and getting the dental work done on Friday as Sunday would be Chinese New Year. I don't perform surgery on Chinese New Year although I am not superstitious about bad luck if the vet "cuts" on Chinese New Year.

I told my associate vet that I would be handling the case myself as there was great worries for the fair lady.

SECOND VISIT
Friday, January 20, 2012

Sunday will be Chinese New Year's Eve. So the dog was done today. Blood test taken revealed nothing abnormal. "You have checked the blood test?" the young lady asked me. "Yes, the blood test showed normal results. There is no kidney or liver disorders and the dog's heart is good. Come back 2-3 hours later." She was comforted and left with her significant other.


ISOFLURANE + OXYGEN ANAESTHESIA
Chihuahua, Male, 8 years, Severe stage 4 periodontal disease.
No sedation
Images of the process and procedures

Mask and then intubation. Many assistants don't know how to anaesthesize the dog using just isoflurane + O2 as the dog does struggle vigorously and bite at a certain stage.
The technique is to hold the dog by the scruff of the neck and to take out the mask when the dog struggles at the excitement stage. Wait a few seconds and put the mask on. Repeat again. Normally, the dog will be anaesthesized smoothly.

Ideally, the dog should be sedated, given isoflurane by mask and then intubated. This is the better restraint and saves much time as the excitement stage does not exist. Most vets use this method and this is the method taught by the veterinary professors. I don't know whether they teach the use of isoflurane solely in old dogs or not as I was a student 40 years ago.

In this case, the owner had some knowledge of the sole use of isoflurane gas done by me and asked me about it. So I took over this case from my associate vet to give her peace of mind. Usually dental scaling is a relatively easier surgery compared to others like spay.

An endotracheal tube of the appropriate size, not too small, is inserted and the dog given 1-2% isoflurane gas as maintenance. The proper sized endotracheal tube for this dog was 6.5

Only 3 teeth left. Around 16 extracted.

The dog coughed when the owners came to pick up 2 hours later.
"It is caused by throat irritation of the endotracheal tube," I explained. "I inserted the tube into the windpipe to give the anaesthetic gas. I will give an injection."

It was one of those satisfying moments to see the young lady smile and freed of worries since her Chihuahua had not died on the op table and was as alert as if he had not been under anaesthesia. Isoflurane anaesthesia effect disappears within 5 minutes and that is why this dog was as alert as normal.

However, it takes a longer time to anaesthesize the dog and there is a certain technique which I taught my assistant Min so as not to injure the dog when he is struggling before being asleep. If a sedation injection is given first, there is virtually no struggling. As I had promised the owner that I will use gas only, I kept my word.

CONCLUSION
Anaesthetic deaths during dental scaling are rare in practice. Anaesthetic consent forms worry many owners and the risk of anaesthetic deaths promote a window of opportunity for non-veterinarians to provide dental scaling services.

Regular dental check up once a year and tooth brushing would have prevented the loss of 19 teeth and much worries. Do spend time brushing your dog's teeth at least three times a week. Easier said than done. A vast majority of Singapore owners is too busy to do the dental brushing.

CREDITS

COMMUNITY EDUCATION FROM TOA PAYOH VETS --- toapayohvets.com

Produced by: Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Narrated, Edited and Filmed by:

Sponsored by:
Asia USA Realty (asiahomes.com) Pte Ltd --- asiahomes.com
Be Kind to Pets (bekindtopets.com) LOGOS

Singapore, Jan 24, 2012

For more info:
W: toapayohvets.com
E: judy@toapayohvets.com
T: +65 9668-6468




DRAFT FOR VIDEO PRODUCTION IS AT:
http://www.bekindtopets.com/animals/20120124isoflurane-gas-dental-extraction_Singapore_ToaPayohVets.htm

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