Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074 Tel: 6254-3326, 9668-6469, 9668-6468.
21 May, 2015
Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles &
A Facial Wound did
Oro-nasal fistula follow up 6 years later
Dr Sing Kong
Yuen, BVMS (Glasgow), MRCVS
Case written: November 15, 2007
21 May, 2015
"Why didn't you come for the surgery?" I admonished the lady owner of the
Pomeranian. "You wasted more money buying more antibiotic powder from the
pet shop to dust onto the facial wound, hoping it would heal.
You can see the wet wound under the left eye in the image
below. It is a classic presentation of an oro-nasal fistula, also known as
malar abscess or carnaissal tooth abscess.
"For ordinary skin wounds, the antibiotic powder would heal them, but I
had already explained to you why the wound would never heal without dental
extraction of the infected tooth."
Her 4-year-old Pomeranian had a
weeping wound of around 0.5 cm in diameter below the left eye, above the
maxillary 4th premolar tooth. It did not heal over the past weeks despite
various medications and powders she had sprinkled on.
Some 14 days ago, I had patiently
explained to her by illustration how the infection from the root of the
maxillary 4th premolar had spread into the nose from the diseased gums to the
skin below the eye.
The bacteria from the decayed roots of this premolar had dissolved the
nasal bone area and made a hole. This condition is called an oro-nasal
fistula. Dental surgery to remove the infected premolar would resolve
her Pomeranian's non-healing wound problem once and for all.
"The vet did a slick sales presentation to make me spend money
unnecessarily" the husband of the dog owner must have told her. "How
can a rotten tooth inside the mouth cause a hole on the skin below the
left eye. This doctor is nuts and is desperate to make money. Mouth and
nose. So far apart. How can there be a connection?"
Back to the present, I said,
"Surgery was to be done 7 days ago after 7 days of antibiotics. But you
did not turn up till today --- 14 days later!"
The middle-aged lady shook her head. I forgot my bedside manners by
scolding her. The customer is king. The general anaesthesia and tooth
surgery was affordable for her as I had discounted my fees.
That savings could buy another sari from Niven Road's sari shop.
I was annoyed because there was an optimal time to do extraction of the
infected and decayed tooth. It was after 7 days of antibiotics and she had
not kept her appointment nor cancelled it.
She just did not turn up
as there was less weeping of the wound due to antibiotics. However after
the course of antibiotics, the bacteria in the infected teeth had resumed
their attack and the facial wound became wet and bleeding again.
The lady pulled up her fine and most colourful sari and smiled sheepishly,
"My husband wanted to use the money for the dog's anaesthesia and surgery
to go to India for holiday lah!"
Now that the dog is no longer on antibiotics, should I operate? There was
no urgency in the sense that it was an emergency. But it would be in the
best interest of this poor dog to be cured as soon as possible.
The Pomeranian's teeth were not brushed at all as this is a common
practice in Singapore.
Initially bacteria attacking the
food debris on the tooth gum line would die in 3-5 days to form a
plaque on the tooth surface. As the dog's teeth were not brushed daily
or at all, more plaque accumulated on the surface of the teeth.
Soon they become tartar (calculus). The gum became infected,
leading to gingivitis. The root of the 4th premolar tooth of the
upper jaw became abscessed due to bacterial attack. Abscess tracked
upwards towards the nose and side of the face. Soon a facial wound appears
to form a connection (oro-nasal fistula) between the tooth and the skin,
discharging pus daily. As the pus and fluid from the mouth is discharged
daily, the wound can never heal as it is always infected.
The decayed 4th premolar and lst
molar became loose as their roots had been exposed as the diseased gum
diseased shrivelled. The supporting structure of the teeth was weakened by
the bacterial attack, leading to a loose tooth that would fall out in time
At this time, there was no choice but to extract these two loose teeth.
Otherwise the Pomeranian would suffer from daily toothache as the owner's
husband might thwart her from doing the right thing for her dog. I put the
Pomeranian under general anaesthesia gas and got the offending teeth
extracted and scaled the other good teeth to remove the tartar.
BLOOD TEST & OTHER PROCEDURES. There
was no pre-anaesthetic blood tests to assess the liver and kidney
functions and blood cells of this younger Pomeranian. Veterinary costs
would be additional $150.
Most likely the poor Pomeranian would not receive any veterinary attention
if an increase of $150 was added to the veterinary expenses.
Therefore I did not require blood tests to lower the
Physical examination of the Pomeranian indicated that there was no cardiac
problem and there should be no death from general anaesthesia. The dog's
anaesthesia was uneventful. He went home on the same day and had no more
facial wound below the eye since 2007 to 2013. I
was fortunate to get an image of the Pomeranian in 2013 as shown below:
2007 image of the Pomeranian
The image below showed the Pomeranian just after
removal of the bad teeth.
The facial wound
closed after a few days when I phoned the lady owner to follow up
after extraction of the infected teeth.
"You are a good vet," the lady
surprised me with her compliment especially after my admonishment.
She wasfree from the chore
of having to clean the facial wound daily.
Her dog was more active and
has a livelier demeanour. And what more joy could a lady have than
to see her companion having a higher quality of life?
2013 image of the Pomeranian
with no oro-nasal fistula
UPDATE IN FEB 2013
I have not seen the Pomeranian since 2007. He was 4 years old then. In Feb
2013, the owners came with the Pomeranian asking me where
to board the dog for
Chinese New Year. I took the following image of him with a face that has
no more oro-nasal fistulas for the benefit of readers.
Yearly dental check-ups may prevent tooth
decay and gum infections and painful eating for your dog and cat. For dental check-up and scaling
appointments, tel: 6254-3326,