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WINTER 2009: PONCHO Poncho, a 4 year old neutered male Shepard Mix, presented for a complete dental examination. The owner was concerned that the patient had very dirty teeth. Since the dog was adopted, the only medical history we could get was that the dog contracted the Distemper Virus as a puppy. On physical examination, the dog had a body temperature of 100.8 degrees Fahrenheit, a heart rate of 110 beats per minute with no murmur auscultated and a respiratory rate within normal limits. His body weight was 13.1 kilograms. The ears were clean, eyes clear, and the abdomen felt normal during palpation. A Chemistry panel and CBC Comprehensive panel was taken prior to induction and was normal. Our physical exam was within normal limits. Thoracic radiographs were not taken to check the status of the heart prior to anesthesia. Oral examination on the awake patient was performed revealing a permanent dentition with moderate enamel hypoplasia, a prognathic occlusion, anterior crossbite on 301, 302, 303, and attrition on all maxillary and mandibular incisors.  
The patient was premedicated with glycopyrrolate[1] (0.01mg/kg SQ) and hydromorphone HCL[2] 0.05mg/kg SQ). A 22 gauge cephalic catheter was placed and the patient was induced twenty minutes later with propofol[3] (3mg/kg IV) and diazepam[4] (0.2mg/kg IV). He was then placed on a Lactated Ringers Solution[5] at a surgical rate of (140 ml/hr IV) for the duration of the procedure. The patient was maintained with a gas mixture of isoflurane[6] (1%) and oxygen (1-liter/minute) flow rate via a 6-mm cuffed endotracheal tube. At the time of intubation, there were no abnormal findings of the tongue, soft and hard palate, tonsils, or larynx. Intraoperative monitoring consisted of blood pressure, ECG, Spo2, cardiac and respiratory rates. The body temperature was maintained with the use of a heating pad in conjunction with a hot air warming unit. Intravenous cefazolin[7] (10 mg/lb IV) was given after induction and was repeated every 2 hours. While under general anesthesia, the following was noted: all of the teeth are following the normal eruption schedules. The patient was given a periodontal index of 3 (PD3) due to 40% bone loss noted on 102. Incisor 202 was fractured with pulp exposure. Tooth 304 was non-vital with pulpal hemorrhage. All of the teeth displayed severe enamel hypoplasia on both the inside and outside surfaces. A malocclusion of class-3 was given to this patient with a slight class-1 anterior crossbite of 301- 303. Some attrition of the incisors was seen due to the patient’s abnormal bite. Intraoral dental radiographs were taken and revealed complete resorption of the incisor 202 root with a large lucency incorporating the space where the root would have been. An endodontic file was passed through the opening of the canal to demonstrate pulp exposure. Tooth 304 was non-vital displaying periapical lucency and a wide canal. All other permanent teeth showed only enamel hypoplasia. Our treatment plan was based on the above examination and radiographic findings. A left infraorbital nerve block was given using 0.3 ml of 0.5% Bupivacaine.[8] A surgical extracting was performed on 202 to remove the resorbed non-vital tooth. A free gingival flap was made with a size 15 surgical blade and the alveolar bone was removed using a high-speed handpiece fitted with a surgical #2 round bur. Intraoperative radiographs showed that no root fragments were left behind. Radiographic interpretation of tooth 304 revealed no resorption of the apex. This tooth was a good candidate for root canal therapy and a referral was made to a Board Certified dentist. 
Treatment for enamel hypoplasia begins with a radiographic record of all affected teeth to determine which are healthy or diseased. Other than teeth 202 and 304, all other teeth were relatively healthy. Because of the patient’s extensive enamel defect, our goal was to do one quadrant at a time to speed up the process and reduce anesthesia time. We started with a light scaling with an ultrasonic scaler taking care not to damage the exposed dentin. A White Arkansas Stone bur was then fitted to a high-speed handpiece and the diseased dentin was carefully removed. Water was used to rinse the teeth clean, then air dried. An etch gel[9] was applied and left on the prepared area for 15 seconds, rinsed off with water for 20 seconds then lightly air dried. A light curing Dentin Bonding Agent[10] was brushed to prepared surface then light cured for 10 seconds. A flowable light cure composite, Revolution[11] shade A1 was applied to fill in defects then light cured for 40 seconds with a visible light curing unit. Once completely cured, we contoured and finished the tooth with Shofu[12] Super Snap disks. Finally we applied a layer of Prime & Bond[13] for a smooth finished shine and light cured it with a visible light curing unit. All four quadrants were restored, including the lingual, labial, palatal, and buccal surfaces. No complications were encountered during the procedure and the recovery was uneventful. 
The patient received hydromorphone[14] (0.05 mg/kg IM) for post-operative pain management at discharge and the owner was instructed to administer clavulanic acid/amoxicillin[15] (125 mg tablets PO BID x 7 days). The patient was discharged from the hospital later that evening with a recommendation to recheck the extraction site in two weeks. Also recommended was the consultation with a Board Certified Dentist to perform root canal therapy on 304. Soft chew toys were also recommended to prevent chipping of the restorative material along with daily brushing. Unfortunately, the owner declined a recheck visit, but communication over the phone revealed that the dog is doing fine and the restorative material is still intact. Poncho and his owner are very happy with his new smile. This case was submitted by Melisa Coleman, LVT, VTS (Dentistry).
[1] Glycopyrrolate, American Regent, INC., Shirley, NY
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