By Dr. Becker
As part of my ongoing Highlighting the Healer series, today, I have a very special guest, my friend and colleague, Dr. Stephen Juriga, who is a veterinarian and veterinary dentist.
Dr. Juriga owns River Heights Veterinary Hospital and Veterinary Dental Center in Oswego, Illinois. He is the veterinary dentist I refer all my patients to. Where I work, we perform prophylactic cleanings and remove baby teeth -- but that's the extent of our dental services -- we refer root canals and extensive oral surgery to a specialist. Since I practice proactive wellness, I focus on lifestyle medicine. I don't handle emergencies, and I refer patients as necessary to other veterinarians. We use a network of specialists to handle everything that falls outside of lifestyle medicine, and Dr. Juriga is the proactive veterinary dentist we refer patients to.
Early in his career, Dr. Juriga realized that maintaining oral health is one of the best investments we make toward the overall vitality and comfort of the animals in our care.
Dr. Juriga is one of only about 100 veterinary dentists in the U.S., plus only about 35 more worldwide. He explains that dentistry has been a very rewarding career change for him, after being a generalist for many years. He bought a general veterinary practice in 1992 and grew it from two to six doctors. He also became accredited with the American Animal Hospital Association (AAHA), which was very important to his practice in terms of setting standards in all levels of veterinary medicine, including pain control, medical records, staff training, anesthesia monitoring, and many others.
Dr. Juriga's interests were surgery and dentistry, and ultimately, he had an opportunity to return to the University of Illinois and study under a board-certified dentist and oral surgeon, Dr. Sandra Manfra. He completed an alternate pathway training residency over four years at U of I, going part-time while still seeing patients at his practice. It was a huge undertaking, involving studying under Dr. Manfra, publishing case reports, and having over 1,000 cases reviewed by her. Then he had to put the entire package together and sit for the boards, which he passed in 2007. These days, Dr. Juriga's practice is about 80 percent dentistry and 20 percent general veterinary medicine.
Dr. Juriga says he always wanted to be a veterinarian. He grew up on a farm, and a local veterinarian would come by to treat the animals. Afterwards, he'd sit down and have dinner with the family, and tell colorful, interesting stories about his experiences in veterinary school, or when he was growing up, or something that happened last week with one of his patients. He was one of the Dr. Juriga's early influences.
While in general practice, Dr. Juriga recognized the need for specialists in veterinary oral health. He realized that returning oral health to pets is one of the best investments we can make in their overall health and comfort. And according to some reports, maintaining the oral health of a dog can add up to two years to his lifespan.
Cavity in a Dog
Complete Restoration (Filling)
Dr. Juriga receives a lot of feedback from clients that once their dog's dental problem is fixed, many patients start behaving like a puppy again. That's how much difference a healthy mouth can make to an animal's comfort and quality of life.
Dr. Becker and Dr. Juriga have collaborated on the care of many patients over the years, including Porkchop, a geriatric dog with a serious heart murmur and a chronically infected mouth.
I remember the case of an elderly little dog named Porkchop with a very serious heart murmur – a grade 5 out of 6. Dr. Juriga and I worked together to help Porkchop. The dog was an anesthesia risk, but his mouth was so dirty and infected that it was a matter of time before a systemic disease took him down. So we had to risk anesthesia, but we got little Porkchop's mouth all cleaned up and cleared his infection. His heart murmur improved to a grade 3, just from resolving the chronic infection in his mouth. Porkchop's overall well-being improved, along with his quality of life.
Tartar & Gingivitis in a Dog
Deep Pocket in Gum
Severe Disease Requiring
Those of us who are believers in holistic health recognize that the mouth is a portal for infection that can affect the entire body. That's why I appreciate Dr. Juriga so much – not all specialists have his proactive, integrative mindset.
Dr. Juriga feels that all veterinarians should act as extensions of each other's practices. Each of us has things we are very good at or prefer to do, and we should be able to refer our patients to other vets for procedures we don't do often. He explained that he recently referred his dog to a veterinary surgeon for bloat surgery, as well as the intensive care he needed post-operatively for two days.
I always advocate assembling a team of healthcare professionals for your dog or cat, including an emergency clinic if your regular vet is only open 9 to 5. You may also need other experts on your pet's team, like a veterinary orthopedic specialist, a cardiologist, an acupuncturist, or an animal chiropractor.
The importance of at-home dental care for pets, and why for some animals, professional dental cleanings are a lifelong necessity.
Another thing we do at my practice is talk to owners of new puppies and kittens about the importance of preserving and maintaining their pet's oral health. I didn't learn that in vet school, and neither did Dr. Juriga. What we learned was that dirty mouths mean more business for us, so rather than promoting preventive at-home care, we were trained to do nothing more than offer once or twice-yearly exams and cleanings to pets that needed them. That's not a proactive approach, but a reactive one.
Also, even when a client is feeding a high-quality diet, providing raw bones to help grind away plaque and tartar, reducing environmental toxins, and brushing their pet's teeth, there are just some animals for whom that isn't enough. Whether it's poor dental alignment or some other genetic predisposition, certain pets require additional professional oral care.
Missing Premolars in a Dog
Impacted Premolar & Bone Cyst
Dr. Juriga agrees and says that at his practice, like at mine, they start puppies and kittens off the right way by proactively showing owners how to desensitize the dog or cat to having fingers in her mouth. If this is covered during initial puppy or kitten visits, it makes it a lot easier to provide that pet with preventive care throughout her lifetime. He also targets toy breed dogs and other small animals that are more prone to periodontal disease. His goal is to reduce the number of professional teeth cleanings done under anesthesia the pet will need over the years.
He does have certain pets that must come in every six months to a year for professional dental care, but, for example, he also has a client who breeds Yorkshire Terriers and it's been several years now since any of her dogs have needed a professional cleaning with anesthesia because she has done such an outstanding job at home with them.
Veterinary dentists are trained not only in treating and removing teeth, but also in oral surgery, anesthesia, radiology, and orthodontic therapy.
When most people think of veterinary dentistry, they tend to think of fractured teeth. But the specialty actually covers a lot more ground than that. It encompasses everything related to the oral cavity, as well as maxillofacial surgery involving oral tumors and the salivary glands. Veterinary dentists receive training not only in cleaning and extracting teeth, but also in anesthesia, radiology, oral surgery, and orthodontic therapy to improve or repair an animal's bite.
Oral Tumors in a Dog
When puppies and kittens are born, their baby or deciduous teeth come in, and many times they look perfectly aligned and beautiful when they're very young. But as the adult teeth start to come in, things can go haywire. Dr. Juriga and I teamed up in the case of a young Poodle with a lower canine that was erupting in the wrong place. When the puppy would close his mouth, the lower canine tooth hit the roof of his mouth. He couldn't bite down without having pain, so he received orthodontic therapy to tip the tooth into the proper position and relieve his discomfort.
Lower Canine Striking Palate
Incline Plane Orthodontic Therapy
8 Weeks Later-Normal Bite
Most pet owners simply don't know if there's something going on with a dog's or cat's bite, and in fact, many veterinarians don't know either. Dr. Juriga uses pictures, dental x-rays, and newsletters to educate referring vets about what to watch for in their patients.
Dr. Juriga thinks six weeks of age is the right time to start providing oral healthcare to puppies and kittens. Conditioning pets from six weeks to six months to accept oral exams and brushing is important, as is a thorough oral exam by a vet once a year.
The two-tooth rule, fractures, abraded teeth, and other common pet dental problems.
Some pet parents don't realize that if baby teeth don't fall out as adult teeth grow in, there will be problems. If a baby tooth stays in place, that means the adult tooth comes in in the wrong position. Depending on the animal's bite, especially in cases of narrow-faced dogs like Poodles, it can cause a malocclusion (misalignment of the teeth). It can result, as in the example used earlier, of a tooth striking the roof of the mouth every time the dog bites.
Persistent Deciduous (Baby) Teeth in a Dog
Dr. Juriga explains that in puppies four to six months of age, the adult teeth should erupt through the root structure of the baby teeth, causing the baby teeth to fall out and the adult teeth to erupt into the correct position. When this doesn't happen and the adult tooth is visible next to the baby tooth, he refers to the "two tooth rule." In those cases, the baby tooth should be extracted as soon as possible. Simply extracting the baby tooth will allow the permanent tooth to erupt into the correct position.
Persistent baby teeth are common in young animals, and so are fractured baby teeth. Fractured baby teeth often become infected because puppies are constantly putting things in their mouths, including things that don't belong there.
Fractured Baby Teeth (and an Abscess) in a Dog
Another problem are tooth fractures at midlife. And some dogs wear down their teeth. They become flat, almost like a cow's teeth. And many pet owners don't realize this can create serious problems for the dog, including risk of infection, pain, and systemic disease.
Dr. Juriga says that tooth fractures and abrasive wear on teeth are problems he tries to identify early. He counsels owners of dogs with abraded teeth that they need to offer food, constructive play or exercise, recreational bones and other items that aren't abrasive or hard on the teeth. The teeth of dogs and cats have less than one millimeter of enamel, and when pets wear through that enamel, they expose a hard substance called dentin.
Dentin is porous, and in most cases it can seal itself. But over time, and especially if the wear on the teeth is rapid, there's a risk that bacteria from the oral cavity will get into the pulp of the teeth and cause an infection. Dr. Juriga performs digital dental x-rays in those situations, and if there is pulp exposure, he recommends either root canal therapy or extraction depending on the functional importance of the tooth and the overall health of the patient.
Enamel Defect Allowed Bacteria to Enter Pulp
X-ray of Tooth Root Infection and Abscess
Some fractured or infected teeth are better candidates for extraction than others. Sometimes a pet will do better having an important tooth saved with a root canal.
Police Dog w/Root Canal Therapy & Metal Crowns Crown Before Fitting/Cementation
Why pulling a pet's tooth can be the best course of action.
Many pet owners are very surprised when their vet or veterinary dentist recommends a tooth extraction. They'll say, "Are you kidding me? You want to pull my dog's tooth? But he's eating fine and acting fine!" My response is always that we don't know the amount of pain, and perhaps constant pain, the animal is in. In fact, studies have shown an animal will experience pain in any condition expected to produce pain in humans. Damaged teeth are painful, they do become infected, and can serve as portals for infection throughout the body.
What many people don't realize is that removing a damaged tooth or performing root canal therapy can provide a healthy long-term outcome, whereas an infected tooth can do the opposite. Dr. Juriga says that many pet owners are reluctant to agree to extractions, until he educates them on the problems of pain and potential infection of the bone. Ultimately, the infection can enter the bloodstream, and can result in liver, kidney, or heart disease – all from a chronically infected tooth.
Why even older and sick pets can be safely anesthetized for dental procedures, and the value of digital x-rays in finding problems lurking beneath the surface.
In older pets, other concerns arise. The biggest fear of owners of senior pets that need dental procedures is, as you might guess, anesthesia. Veterinary dentists like Dr. Juriga receive extensive training in anesthesia and also pain management. He has anesthetized hundreds of our mutual patients, including many older animals with significant health issues like kidney, liver, or heart failure, and he's never lost a patient. Now, that doesn't mean there are not risks associated with anesthesia. The keys to anesthetic safety include a pre-anesthetic examination, blood and/or urine profile, and possible chest x-rays. These tests are followed by the development of an individualized anesthetic protocol that includes premedication, intravenous catheter, fluid therapy, intubation, thermal support, patient monitoring, dental nerve blocks (when needed), and nursing care that extends into the recovery period. Basically, we both believe that veterinarians should strive to provide all the things human anesthesiologists provide to human patients.
Another problem some pet owners have is with x-rays. They don't want their dog or cat exposed to radiation, or sometimes they just don't want to pay for it. Thankfully, x-ray technology has evolved and now veterinarians have access to digital radiography, which virtually eliminates radiation exposure. And what many pet guardians don't realize is that digital x-rays are crucial in identifying issues beneath the surface of the gums.
Dr. Juriga refers to a study done by the University of California-Davis that showed 42 percent of cats and 28 percent of dogs had oral pathology that could only be diagnosed using dental x-rays. A normal oral exam with a periodontal probe, even with the animal anesthetized, cannot reveal every problem lurking beneath the surface. That's why Dr. Juriga insists on dental radiography with every patient, typically twice during the lifespan of a dog or cat with a normal, healthy mouth -- say a set of films at age five and another at age eight.
Gum Infection in a Cat
The kind of veterinary dentistry Dr. Juriga practices, which is quite thorough and identifies issues that could be a problem in the future, is the antithesis of today's current trend toward anesthesia-free dentistry. Non-professional dental scaling (NPDS) (another name for the procedure) involves cleaning just the surface of the teeth of a fully awake pet, without evaluating what's going on below the gum line or in other unseen areas of the oral cavity.
Gingivitis and Gum Recession
Dr. Juriga believes that NPDS is confusing to pet owners because on the one hand, they fear having their pet anesthetized, but on the other hand, they don't understand the real limits of an essentially cosmetic dental procedure that cleans just the surface of the teeth. It's the equivalent of going to your own dentist and not allowing use of a periodontal probe to check for pockets or bone loss, or x-rays to check for cavities or infection. He feels pet owners need to realize that in capable hands, the risk of anesthesia for dental procedures is far, far less than the risk of the systemic effects of untreated periodontal disease.
X-ray Showing Bone Loss
Thorough pre-anesthetic workups are crucial, and should include chest x-rays if necessary, bloodwork, and a physical examination. Patients should also receive a pain pre-medication that reduces the required dose of all other drugs that will be used. It's called balanced anesthesia, and employs an effective pre-medication to reduce the dose of the induction agent and the maintenance agent used to put and keep the animal asleep.
And for dental procedures, regional nerve blocks like novocaine are also used to block pain before it occurs. Dr. Juriga is able to keep patients on a lighter plane of anesthesia throughout the procedure thanks to the pre-medication and novocaine for pain control. Recovery from anesthesia should be rapid and is always monitored by a veterinary technician. In his practice, pets are awake in two to five minutes and are typically standing within 15-20 minutes.
As pets age, they tend to develop diseases, for example, diabetes, or heart or kidney disease. Their immune system isn't as resilient as it once was. And periodontal disease in aging dogs and cats tends to progress more rapidly. Both at-home and professional dental care should be done more frequently in older pets, for example, brushing their teeth twice a day instead of just once a day or every other day.
Before and after dental pictures are very helpful in targeting the areas of a pet's mouth where tartar and plaque are most likely to accumulate. And Dr. Juriga believes in using these photos at the dismissal appointment to develop a customized home care regime best suited to each pet owner and pet.
Recreational raw bones and oral health.
Dr. Juriga is supportive of raw food diets, including bones, but he does see his fair share of fractures in pets on such diets. I've mentioned my veterinary dentist in several videos and articles here at Healthy Pets on the subject of appropriate recreational bones and chews for dogs, and now you're meeting him!
I spend a lot of time with clients going over detailed recommendations for appropriate recreational bones for their dogs. Some of those clients think I'm overreacting, but part of the reason I'm so detailed and thorough is to hopefully avoid fractures and other chew bone-related catastrophes. There are some dogs for which no bone or chew is appropriate because they are just too aggressive, or they've already broken too many teeth.
Dr. Juriga sees hundreds of cases of fractured teeth as a result of inappropriate raw bones, and not just from my practice. Antlers are often a problem. So are Nylabones. Anything you can't put a dent in with your fingernail has the potential to fracture the crown of the tooth, similar to ice cubes and human teeth.
Various Types of Tooth Fractures in a Dog
It's not that recreational bones and chews are terrible. It's that it's very important to pair the personality, breed, age, and tooth condition of the dog with the right type of chew. One size does NOT fit all when it comes to recreational chews and bones. One of the reasons I wanted to do this interview with Dr. Juriga was to hopefully give viewers information that will help them work proactively to protect and maintain the oral health of their pets.
Many thanks to Dr. Juriga.
Dr. Juriga is truly a blessing to general veterinary practitioners. He even sees zoo animal patients, and clients drive from great distances to bring their animals to him. So if your own pet has a dental problem that is beyond the scope of your local veterinarian's expertise, you may want to consider finding the nearest veterinary dentist and making the drive.
Dr. Juriga Performing Root Canal Therapy on an Amur Tiger (Left) and Repairing a Fractured Canine
Tooth in Another Tiger (Right)
I want to thank Dr. Juriga for talking with me today, and for helping my readers and viewers understand the importance of maintaining their pet's oral health. If you're interested in locating a veterinary dental specialist near you, you can visit the American Veterinary Dental College website and click on the "Locate a Veterinary Dental Specialist" link in the upper right-hand corner.
In the final 15 minutes of the video, Dr. Juriga performs a dental procedure on a patient and walks viewers through exactly what he's doing and why he's doing it.