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Focus: Small animals -dogs, cats, guinea pigs, hamsters, pet rats and mice, birds and turtles      
October 02, 2020

Case study written in 2010

Dr Sing Kong Yuen, BVMS (Glasgow)

Old dogs do suffer from carnassial tooth (maxillary 4th premolar) abscesses. Some vet mis-diagnosed the non-healing facial wound as due to traumatic wounds and prescribe antibiotics. The owner wound need to consult the vets for several months as the medication did not lead to the healing of the facial wound. If the vet correctly diagnosis the condition as an oro-nasal fistula, also known as carnassial tooth abscess, the only treatment is surgery to remove the infected tooth. However, the dog would usually be old, in poor health and would have a high risk of dying on the operating table.

When told of a high risk anaesthetic death on the operating table, many owners opt out of surgery. The dog's health deteriorate as there is infection and loss of appetite. Eventually, most owners must decide on two choices. A prolonged painful death from malnutrition and infection. Or a possible death from cardiac failure arising from anaesthesia while the dog is having dental work on the operating table.

Vets are not Gods. It is foolish for the vet to say that the dog has a high percentage of survival when the dog is in poor health. Well, if the dog has a poor chance of survival, some owners think: "This vet must be no good".

The vet senses that there is a loss of confidence in him or her. There is a tension in the consultation room when the owner expresses his sentiments about the vet's competence if there is death from anaesthesia during treatment. What should the vet do? Should he advise antibiotics regularly so as not to take the risk of anaesthetic death and also the damage to his professional reputation when such deaths occur. Owners are likely to bad-mouth him and change to another vet under such circumstances.

Advise the owner to seek second opinions rather than continue conservative medical treatment for several months

Is it morally ethical to milk the owner as a cash cow knowing that surgery will cure but the risk of anaesthetic death on the operating table is extremely high?

If the vet feels that it is too risky to do anaesthesia on old dogs or pets, ask the owner to seek other vets who may take the risk and ruin his reputation. News of death on the operating table spread like wildfire on the pet internet forums and social media. The reality of the situation is that the dog will not be cured on conservative medical treatment. Therefore the owner must be told firmly and give written consent for anaesthesia to prevent misunderstanding.

Economic reality may override the moral ethics in a private practice with so much competition and high overheads. The staff and associate vets see what you do if you are the leader in the practice. Do the right thing by asking the owner to seek treatment elsewhere once the owner has had lost the trust in the veterinary-client relationship with the vet.

Vets are not Gods. Deaths on the operating table will present themselves to every practising vet. Bad-mouthing do spread like wild fire when you handle high- risk anaesthetic cases in old dogs as there will always be owners who delay treatment or ignore veterinary advices till they have no choice except surgery.

In this carnassial tooth case recorded here, I did not phone Vet 1 as to why medical treatment and cleaning of the facial wound were performed for one year for "sinusitis" owing to a yellowish nasal discharge from the left nostril for one year. The owner had confirmed that Vet 1 had diagnosed correctly the condition. "He just would not operate on the dog." This was the point of view of the owner whose mother was the one in contact with Vet 1.

The mother would have to visit him many times to seek a cure. Finally, the son took the high anaesthetic risk to get the dog operated at Toa Payoh Vets.

A blocked left nostril with yellow discharge. A cyanotic tongue indicating a lack of oxygenated blood or toxicity. These symptoms signal high anaesthetic risk.  This 11-year-old Chihuahua was in excellent body condition, not being thin. I auscultated the heart. Surprisingly, she had no heart disease.

These were the pluses but still one cannot be too complacent. Only 11 out of 42 teeth existed and they were loose ones with tartar built up over the years. Vet 1 had done one dental scaling some years ago. So, there was a good veterinarian-client relationship with the owner's mother. But now he would not risk his professional reputation to do any anaesthesia on this old Chihuahua.

But that facial wound oozed pus daily. The discharge soiled the apartment floor and bedding.  That rubbing of the left eye causing eye pain and tears to flow freely. That left nostril discharge of yellow fluid of bacterial cells. These unpleasant occurrences had gone on for almost 12 months. The mother was stressed out seeing her companion suffering and soiling her bed and face.

In real life, it is the aged parents who feel so much more for the companion dogs since the children have left the nest and have practically no time for the senior citizens. So, it would not be a surprise to me if this case had become extremely emotional for the mother who treated this Chihuahua as her child more than a mere companion. Mothers are like that, unlike spouses who may get rid of the sick pet that needed daily care for 12 months! Yet mothers cannot be expected to tolerate soiling of the apartment and her "child" if there is a surgical option to cure the "child".

The irony of this case is that surgery would cure. Yet Vet 1 just did not want to do it due to the high risks involved. In this case, the son took matters in his hand to seek my opinion. He accepted the high risks. We had never met before. Much was at stake for the mother. If the outcome was good, the mother would be most happy as this Chihuahua is family to her.

I used isoflurane gas anaesthesia with no sedative injections. It was difficult to mask the dog as she had this left nostril discharge. I intubated using a smaller endotracheal tube. This type of cases must be on short duration of anaesthesia to achieve a good outcome. The vet must have all instruments ready. I even had the dental scaling machine switched on.

The 11 loose teeth were extracted with speed. It was possible to leave the canine teeth alone to comfort the owner that the Chihuahua had some teeth. But that would not be in the interest of the dog. They were only slightly loose. But I know that this old dog would get gum diseases later and this would be her only chance under anaesthesia. So I took out all the teeth instead of doing dental scaling on the canine teeth.


7 days later, I phoned the son. He was quite grateful and said: "Mum does not need to wipe away the runny nose (left nostril discharge) or clean the tearing eye (left facial wound, dog rubs itchy wound and eye). I know I will never see the mother who must be in her sixties. She is now a happy mother and there will be peace in the family after 12 months of worries. I did notice a swelling on the right cheek and a possible carnassial tooth abscess on the right side. Now, since all 2carnassial teeth had been extracted, I would not see a case with two oro-nasal fistulas - a rare case but I did encounter one such case

7 months later, I saw the Chihuahua for an upper respiratory tract infection. The left facial area was clean and free of the non-healing Oro-nasal Fistula, also known as Carnassial Tooth Abscess.

The family vet prescribed antibiotics for the past 12 months as he did not want to risk his professional reputation. This old runny nose Chihuahua might die on the operating table during anaesthesia to extract the carnassial tooth abscess. However, extraction of this tooth would stop the purulent discharge from this abscess within 7 days. No more stress in the household as the mother sees the dog soiling her face and the apartment daily for 12 months.  
Refer the case to other vets if you don't want to risk your professional reputation of anaesthetic deaths in high-risk ill patients with respiratory infections as the social media bad mouthing of such deaths is prevalent.
At 7 months, I saw this beloved old Chihuahua. Her left face was clean and has no oro-nasal wounds.

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