12/19/2002 Entry: "The Dental Dilemma"

Article from The Whole Horse Journal, September/October 1998. You may obtain a subscription to The Whole Horse Journal by calling 1-800-829-5580.

All graphics are located on the side or top of this article (ignore the graphic locations which the article specifies).

The Dental Dilemma
What care does your horse need, and who should provide it?

BY NADINE LAVELL / PHOTOS BY ELVIRA LAVELL

I was professionally involved in human dentistry as a clinical dental hygienist for more than 25 years. Even though I looked in 40 to 50 human mouths per week, and had advanced education, including a masters degree in dental hygiene, it never occurred to me that my horse had extensive dental needs as well. Like many horse owners, I thought I was being responsible if I asked my general practice veterinarian to check my horse's mouth once a year. The veterinarian would then "float" the teeth "if necessary" and we would be set for another year.

However, after watching a highly trained dental professional address the health and balance of my horse's entire mouth, my perceptions changed forever. I now understand proper dental examinations and treatments are among the most important - and the most neglected - aspects of equine health care.

Floating Is Only/A Fraction Of Whole Mouth Dentistry

I've learned that "floating" (the removal of sharp points from the horse's back teeth) is just the tip of the iceberg when it comes to complete dental care. I've discovered that while dental decay is not as common in equine mouths as it is in human mouths, our domestic horses have many, many problems with their teeth that are rarely improved by floating. Many domestic horses suffer from poor tooth alignment and irregular chewing patterns, which can cause severe pain, digestive difficulty, colic, and behavior and performance problems. These conditions also cause neck stiffness and contribute to lameness.

In short, I was so impressed with the positive changes that educated dental care can make in the lives of horses that I changed my own career. After lots of further study and education, I now practice equine dentistry full time.

Dental Education Is Lacking

It's an uphill battle, however. Few horse owners are aware of the benefits of dental work for their equine friends. And most veterinarians - even the ones to most recently graduate from veterinary colleges - lack up-to-date training in dental care for horses.

Unfortunately, not knowing about this critical care can hurt your horse. I learned this first-hand. For years, my well-meaning veterinary professional took care of my horse's teeth as he had been taught in veterinary school. But because his dental training and skills were light years behind those of the full-time up-to-date dental professional, my horse suffered needless dental pain and bite problems. She also had a perplexing soundness problem which turned out to be related to her mouth. Due to the bit making contact with an undiscovered wolf tooth, she had difficulty traveling to the left, mimicking the symptoms of a lameness in her left hind leg. Once her dental problems were corrected, she felt better, ate better, and moved soundly.

Most horse owners are in the same situation I used to be in; their horses may have dental problems that their veterinarians are unaware of or unable to treat. Few veterinarians have the extensive, specialized training and time it takes to become a good practicing dentist. Most receive fewer than 10 hours of formal instruction about the equine mouth during their university schooling. And though recently it has become popular for practicing veterinarians to attend weekend courses which introduce them to advanced dentistry, the courses do not adequately train them.

Often, when you do find a person who has training and experience in providing dental care for horses, you discover that the person is a lay professional - not a licensed veterinarian - who has studied with other professionals to gain the specialized knowledge and skills that the job requires (see "Who Can Be a Good Dental Professional For Horses?" page 6) [please see the September/October 1998 issue of The Whole Horse Journal for article]. But just because someone has years of experience doesn't mean they provide optimum care. So how do you know if an equine dental professional is competent?

The Dental Evaluation Provides Answers

First, the more you know about your horse's mouth and teeth, the more you will be able to ascertain whether your dental professional is capable of finding and treating your horse's dental problems. (For extensive information about full mouth dentistry for horses, see "The Truth About Teeth" and "Watch Your Mouth," published in the May/June 1996 issue of TwHJ, and "Insidious Incisors," published in the July/August 1997 issue.)

To gain as much information as possible, you'll need someone to help you thoroughly evaluate your horse's teeth. Below, I've detailed what should go into a complete dental evaluation. This pre-treatment assessment should give you information about the structure of your horse's head and jaw and a complete evaluation of the teeth - both individually, and how they work as a food-processing unit. This information will allow you to make choices regarding any treatment your horse may need.

Succinctly, the dental evaluation is your opportunity to evaluate the professional's knowledge and horsemanship before they perform treatment procedures which are critical, yet potentially damaging to your horse. If the person who examines your horse's teeth does an inadequate job, you'll definitely want to find another professional to give a second evaluation, and possibly perform the treatment.

By familiarizing yourself with proper procedures and becoming aware of those outdated methods which could hurt your horse, you can screen out unqualified practitioners and make sure your horse receives the quality care he needs.

The Dental Evaluation

I divide the equine dental evaluation into four parts:

1. the pre-evaluation interview
2. the evaluation outside the mouth
3. the evaluation inside the mouth, and
4. the discussion of findings.

While it may seem obvious, expect professional behavior from the dental provider including cleanliness of instruments, promptness and respectful behavior to both you and your horse. Communication is also very important. You should feel comfortable asking questions and the dental professional should be able to respond clearly.

Although others such as a friend, your trainer, or the barn manager may be very knowledgeable about your horse, you hold the responsibility to make decisions and give permission for dental treatment. You need to be present for the initial dental evaluation and discussion of a treatment plan.

1) Pre-evaluation Interview

The pre-evaluation interview takes place between you and the dental professional before he or she looks at your horse. Here are some basic questions the dental professional should ask you:

Why did you make an appointment? I always inquire about the reason I was called. There may have been a change in the horse's eating behaviors or weight loss. The trainer may have noticed a difference in the horse's reaction to the bit or performance changes. The veterinarian may have found dental conditions beyond the scope that he felt comfortable treating. The owner may be requesting a second opinion or want routine dental maintenance.

What is the horse's age? Information about the horse's age helps the dental professional predict the presence of certain teeth and dental conditions. The young horse should be losing deciduous (baby) teeth and gaining permanent teeth along a specific time schedule. When this does not occur, the horse may have life-long dental problems. The middle-aged horse may develop chewing patterns that can prematurely wear teeth down. The senior horse may be unable to chew properly due to loose or worn-out teeth. If dental care has been limited to "floating," horses of all ages may suffer from undiscovered dental problems.

Where does the horse live? What is his diet? In general, there is more desirable tooth wear in horses that live out on pasture and eat native grasses. Horses that live exclusively in a barn and eat cut, baled hay and grain often have improper tooth wear. Confinement may also contribute to chewing vices which result in uneven tooth wear.

Is the horse's weight appropriate? What is the content and quality of the horse's food? Contrary to popular belief, weight gain or loss is only one small factor in determining the efficiency of the horse's teeth. A horse with dental problems may maintain a desirable weight while suffering dental pain and impaired function.

A horse in regular work should be able to maintain his weight if he receives enough quality food and his teeth function properly. A thin horse who is not in active work, but consumes large quantities of food could be suffering from dental problems. Another suspect would be the horse which appears to be in good weight but needs to eat large quantities to maintain this weight.

What is the horse's occupation? Does the horse carry a bit? Has the horse displayed any performance changes? Don't be surprised if your dental professional asks to see the horse's bit and checks to see how it fits your horse. Dental problems will make it uncomfortable for the horse to have a bit in his mouth. The horse with dental problems may chew the bit incessantly, tilt his head, or resist turning, stopping or yielding to the bit.

Once dental problems are taken care of, the dental professional can shape the molars closest to the bit so the horse can carry the bit more comfortably. This procedure is known as making a "bit seat."

Is the horse chewing or eating oddly? It is important to find out whether the horse drops food while he eats, spits out wads of half-chewed food, or leaves any food behind. A horse who takes a long time to eat may be coping with poorly functioning teeth or dental pain.

How is the horse's disposition? The easily spooked or grumpy horse may be reactive or uncooperative due to dental pain. Think of yourself when you have a bad headache: you may become jumpy, overly sensitive, or grumpy. The smallest interruption or noise can be irritating. When the pain is gone, your mood improves and you can easily tolerate daily challenges.
Dental pain may keep the horse in a constant state of stress where even the smallest challenge may cause an extreme reaction. I have seen horses that spooked at the smallest distraction become nearly bomb-proof once their dental problems were corrected.

2) Evaluation Outside The Horse's Mouth

The next part of the evaluation involves looking at the overall horse and the symmetry of the skeletal structure and muscles of his head. I check to see if the horse's weight is appropriate and observe whether he carries his head, neck, and body straight.

When looking at the horse's face, it may be obvious that one eye or ear is located higher than the other, a condition that can effect dental function. I palpate the bony and soft structures of the head and neck with both hands. A muscle on one side of the head may be large and round from overuse while the same muscle on the other side of the head may be flat due to lack of use. This may predict one-sided chewing. Evidence of old injuries may be found.

I also feel the temporomandibular joint (TMJ), which is the attachment of the lower jaw to the skull (you can see the TMJ anatomy in the photo on page 3). The TMJ is often put under stress as a result of poorly functioning teeth. Tenderness, heat, or swelling may be felt around the stressed TMJ during the evaluation.

3) Evaluation Inside The Mouth

The third part of the evaluation includes examining the teeth and all other soft tissue structures inside the horse's mouth. The dental professional will look for many things, including the appropriate number of teeth, the presence of deciduous teeth, wolf teeth, canine teeth, broken teeth, irregular tooth shapes, irregular tooth wear patterns, ulceration inside the mouth, and freedom of the jaw to make normal chewing motions.

Watch this part of the evaluation closely. The dental provider must use quality techniques in order to competently evaluate your horse's mouth. Look for the following beneficial and potentially harmful practices:

SAFE: Use of a full mouth speculum (see Photo 3). The full mouth speculum is an instrument that rests against the horse's upper and lower front teeth to assist him in holding his mouth open. This unusual-looking instrument increases safety for both the horse and human. Most horses find comfort in having a place to rest their teeth.

To prevent strain on the TMJ (temporomandibular joint) the mouth should not be opened any wider than is necessary and should not be held open any longer than necessary. The average horse will remain comfortable with the speculum adjusted so the upper and lower incisors are about 2-1/2 inches apart (see Photo 4 above).

It is critical that the dental professional pay attention to the horse's behavior while the speculum holds the mouth open. A horse that begins to nod or shake his head is often reporting the need for a rest. Frequent rests (so the horse is allowed to close its mouth) will help the horse tolerate the evaluation and prevent strain. This is especially important for a horse with pre-existing TMJ pain.

CAUTION: Use of spools or wedges. Beware of the professionals who use other instruments such as spools and wedges to prop the mouth open, instead of a speculum. These devices must be used with extreme caution. They only support one side of the mouth and if placed on a bad tooth can cause the tooth to fracture. The spool can easily puncture the skin on the roof of the mouth.

CAUTION: Pulling on the tongue. Today we know that pulling the horse's tongue forward or sideways out of the mouth can cause permanent damage. The hyoid bone is in the floor of the mouth and has a thin, fragile extension into the base of the tongue. Pulling the tongue can break or disjoint this apparatus. Pulling the tongue out of the mouth was once commonly done by both veterinarians and dental professionals.

Sometimes it is necessary to carefully hold the tongue out of the way. The knowledgeable professional will move the tongue but carefully keep it within the mouth.

SAFE: Sedation standards. The need for sedation during the evaluation depends upon the horse's ground manners and comfort level, and the horsemanship skills of the dental professional. Sedation is usually required for the actual dental treatment.

Only a licensed veterinarian is legally able to provide sedation for your horse. Unless the dental professional is also a veterinarian, it is neither safe nor legal for him to tranquilize your horse. The veterinarian's job is to determine the correct dosage of the medication by assessing the horse's overall health and metabolism. All horses, especially older or sick animals, must be monitored during sedation to assure their safety. The veterinarian is prepared to treat complications (such as allergic reactions or stress reactions) should they arise.

In addition to providing sedation, the veterinarian often provides pain relief medication, antibiotic coverage, and follow-up care for horses who need extensive tooth reduction or molar extractions, or those horses with infections. . . .

SAFE: Proper technique. The dental professional will use his right hand to evaluate the horse's right side and his left hand for the horse's left side. The last tooth in the back of the horse's mouth is located below his eye. In order to completely evaluate these rear teeth, the dental provider may have to put his arm into the horse's mouth up to his elbow.

SAFE: Use of a flashlight. A flash-light can reveal findings that may not have been felt. Fractured teeth, deciduous teeth, and imbedded fragments may be more easily recognized by sight.

4) Discussion of Findings

The final step of the evaluation is the dental professional's explanation of findings. The explanation will include a description of the general condition of the horse's mouth relative to his age, all specific abnormalities which were found, and an explanation of treatment options.

The evaluation is over when the owner understands all existing conditions and has enough information to make a wise treatment decision. At this point a treatment plan can be established. The plan would consider the horse's dental needs and recommendations for immediate and long-term treatment. It would also take into account the owner's budget and need for veterinary assistance for sedation and other services.

Although there are many parts to a proper dental evaluation, the process should take between 10 and 20 minutes, depending on the discussion time.

An evaluation fee may range from $35 to $50. Ask the dental professional about the fee schedule in advance so that you will be prepared. The evaluation fee will often be waived if you decide to have dental care performed during the same visit. The treatment fees depend on the number of procedures to be performed.

The owner may elect to have the dental care on the same day as the evaluation. It may be appropriate to reschedule for the dental treatment if you want to get a second opinion or if you decide the dental professional is not who you want to perform treatment procedures. Treatment may also be postponed if sedation is needed or the dental findings (such as a fractured tooth or multiple extractions) require referral.

Ask The Tough Questions
For the safety of your horse, be sure to clarify several critical components of dental procedure before you hire someone to evaluate your horse.

Find out if the dental professional uses a full mouth speculum. If the person plans on using a wedge or a spool to prop the horse's mouth open, do not hire him or her.

It is also important to discuss the professional's view of handling the horse's tongue before he or she starts to work. Only hire someone who will commit to keeping the horse's tongue in its mouth.

If the provider is not a veterinarian discuss his or her contingency plans for working with a veterinarian to provide sedation. If the lay professional says they are capable of administering sedation, do not hire them.

Most people have had both good and bad experiences with their dentists and dental hygienists. As the horse owner, it is your responsibility to seek quality dental care for your horse. Through interviewing dental providers and watching how they perform the dental evaluation, you can assure that your horse receives safe handling by a professional who will deliver quality treatment. This will increase your horse's comfort, performance ability and life expectancy.

Who can be a good dental professional for horses?
When looking for an equine dental professional, horse owners have two distinct groups to choose between: veterinarians, who have received varying amounts of training and experience in dental care, and lay people (non-veterinarians) who may or may not have extensively studied and practiced dental work on horses. Unfortunately, it's not easy to determine who is the best-qualified to provide safe, complete dental care for our horses.

At this time, even though veterinary schools provide their students with only minimal education about equine dental care, the state veterinary practice acts give the legal right to perform dentistry on horses to licensed veterinarians. In most states, non-veterinary professionals can work under the direct supervision of a veterinarian as long as they limit their work to simple filing of the horse's molars ("floating"). The work necessary to truly improve a horse's mouth, however, may include balancing molar chewing surfaces, extracting teeth, and cutting the molars and incisors. Most of these procedures are technically considered to be advanced dentistry and are limited by law to veterinarians. Paradoxically, few veterinarians know anything about advanced dentistry while their lay counterparts often receive comprehensive training and specialize in these procedures.

Todd Williams, of Turner Valley, Alberta, Canada, is an executive director of the World Wide Association of Equine Dentistry (WWAED) and an experienced dental professional. He insists that equine dentistry requires many hours of education and hands-on work under the supervision of an experienced dental professional. The WWAED provides education, testing, and certification for equine dental providers, thus offering horse owners a way of ascertaining that the professional they hire has received a quality standardized education in the field.

Despite the laws and the politics, in many geographic areas, veterinarians and lay dental professionals work in tandem to provide complete dental care for their clients' horses. Dental professionals want the veterinarians involved as the primary health care providers. Many veterinarians recognize they are not skilled in this particular area or they are too busy providing other aspects of equine care, and so they work with the dental professionals to ensure the horses receive proper care.

The Dental Dilemma - Directions for looking at your horse's
mouth

Don't examine the teeth yourself! Without the full mouth speculum and necessary training, it is dangerous to try to evaluate the inside of a horse's mouth yourself. Even with the proper equipment and training, equine dental professionals often have cuts on their hands and darkened fingernails. You can safely evaluate the outside of the mouth for symmetry and TMJ soreness (Photo 1). If you insist on looking inside the mouth do so by rolling the lips open to "look" in, but keep your fingers out (Photo 2).

1) While evaluating the structures outside of the horse's mouth, Nadine Lavell checks Angel's TMJ for soreness.

2) Nadine evaluates the alignment of the front teeth and looks for sores caused by weeds or injury.

3) While it looks medieval, the full mouth speculum allows the dental professional to safely examine the teeth.

4) As you can see by Angel's expression, most horses are not distressed by the speculum opening their mouths.

5) The professional must be able to reach back into the mouth and feel the various structures safely.

Nadine Lavell is an equine dental professional and horse owner from Northern California. She practiced as a clinical dental hygienist for humans for 25 years, gaining a Masters degree from the College of Dentistry at The University of Iowa, before redirecting her career to horse dentistry. See "Resources," page 24, for more information.