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Date:   21 January, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

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MORAL ETHICS VERSUS ECONOMIC REALITY
CARNAISSAL TOOTH ABSCESS IN AN OLD DOG

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written:  21 January, 2010

 
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Old dogs do suffer from carnaissal tooth (maxillary 4th premolar) abscesses and unless the vet has not diagnosed the non-healing facial wound as due to the abscess, the owner will need to consult him or her for several months. Medicines will be given and yet the facial wound still does not heal. If the diagnosis of this oro-nasal fistula is correct, the only option is surgery to remove the infected tooth. Unfortunately, the dog is old, in poor health and has a high risk of dying on the operating table.

When told of a high risk anaesthetic death on the operating table, many owners opt for no surgery. The dogs become older and sicker. Finally, the owner has no choice. It would be a prolonged painful death or a possible death 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, the vet must be no good. The vet can sense that there is a loss of confidence in him or her. There is a tension in the consultation room air when the owner expresses his or her sentiments about the failure of treatment. What should the vet do?
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 or her reputation. Death on the operating table spreads like wildfire on the pet internet forums but 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 given written notice 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 and 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 carnaissal 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" due 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.

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 that facial wound. That rubbing of the left eye. That left nostril discharge. These had gone on for almost 12 months. The mother could be stressed out. 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 volatile and emotional for the mother and family members.

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 such cases, I would pass the buck to other vets. 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 anaesthesia to achieve a good outcome. The vet must have all instruments ready. I even had the dental scaling machine switched on just in case it was needed.

The 11 teeth were extracted. It was possible to leave the canine teeth alone to impress or 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.

 

Carnaissal Tooth Abscess in An Old Chihuahua
 

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 carnaissal tooth abscess on the right side. Now, since all 2 carnaissal teeth had been extracted, I would not see a case with two oro-nasal fistulas - a rare case.
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