Pull The Tooth!

This week a horse owner from over a thousand miles away called me after I had gone to bed with an urgent tone in her voice. She has an 8 year old warmblood dressage horse with a lump on her jaw for 4 days. Her vet came out and took x-rays and then pronounced that a tooth needed to be pulled. This horrified the owner and she was seeking out another opinion.

Wait a minute – I need to hit my head against the wall again.

Ahh – that’s better.

This poor owner had been scared by a vet with good intentions, but with only the knowledge of what she had been taught at vet school. While the glamor of performing surgery appeals to surgeons, it is not always in the best interest of the horse.

I just need to remind everyone (again) that we are talking about HORSES and not HUMANS. The teeth are very different. Yet only for emotional reasons we automatically think that if there is a tooth problem, we need to pull the tooth. It’s like Tom Hanks’ character in the movie “Cast Away.” If you didn’t see it, he becomes stranded on a tropical island with a toothache. His only relief from his agony is to knock out his own tooth using a rock and a skate blade. He passes out from the pain for a few days. If this doesn’t make sense to you, then go see the movie. It is a gruesome but memorable scene.

We all can relate to a painful tooth. We all have been to a dentist where they either drill out the abscess or they extract the tooth. We all want relief from the intense pain.

But the horse rarely exhibits pain from an infection near or in the tooth. In fact, they keep eating, as was this mare according to the caller. So why pull the tooth when a less invasive path could be tried?

There have been only a few instances in my three decades as a dentist where pulling the tooth actually helped. They were associated with malformed teeth or disintegrating teeth in young horses. Here the tooth was actually the cause of the infection. Extracting it then is an obvious choice. But realize that extractions have some serious and bizarre after-effects. Just ask the horse owner whose horse had a hole from the mouth to the sinus for several years after extraction.  That horse needed a liquid diet for years until the hole finally closed.

I have plenty of stories where mandibular lumps have resolved with long term antibiotics alone. I also have stories where owners have had a tooth removed plus antibiotics and the problem resolve as well. So which way would you go?
Antibiotics alone? Pull the tooth and antibiotics?

There is no doubt that pulling the tooth resolves the issue quickly. But is it the right thing to do for the horse? If the horse is not bothered by the swelling and continues to chew unaffected by it, then why extract a tooth? I believe they extract the tooth because of the owner’s desire to correct something that they have associated human feelings to, maybe a painful tooth issue they have had themselves.

What is an abscess? It is the body’s way of walling off something bad (foreign object, bacteria) and pushing it to the outside. It is a natural process we have all seen when we watch the ugly zit form on our face or a splinter gets under our skin. To me, it is an absolutely gorgeous event to watch. The body identifying a bad thing, walling it off, and kicking it out of the body. It’s perfect.

Why, then, do we not believe in its good intentions? Cover the effects of the bacteria spilling out of the abscess with antibiotics, but allow time for the abscess to do its job. With teeth, this can take 6 to 8 weeks.

In the years since 1983 of working with horse teeth, almost all the infected teeth resolve on their own with time and antibiotics. The few that did not were extracted, but well before they were given enough time to resolve on their own (a week or two). They were extracted because the owner wanted immediate results and they went to a surgeon very willing to do the extraction.

There is one horse in my practice - a Belgian - who resists every attempt to work on her broken and abscessed tooth with a smelly nasal discharge that needed daily cleaning.  The owners couldn't send the horse in for anesthesia and surgery plus Belgians are difficult to anesthetize.  The result is that we did nothing.  While it took a few years, the abscess resolved on its own and the horse never skipped a meal because it was never in any pain from the problem. Answer this simple question - How many horses have you seen with a nasal discharge from a tooth root abscess? Very few I'd bet. And of those you have seen, how many showed difficulty in chewing? If tooth root abscesses with drainage was such a problem, wouldn't we see horses everywhere suffering from them? But we don't because they are self limiting because abscesses are the end stage of healing. The infection has been going on for YEARS!

This owner who called me that night decided to try long term antibiotics. She was willing to let the horse resolve this abscess on her own and I was pleased with her decision. But then something happened. She became tired of hot packing the jaw every day and the other vet put pressure on her saying that the visiting specialist vet who could do the extraction had limited time in the area and would be there in a few days. The owner decided after only a week of antibiotics to have the tooth extracted from her horse.

This is cheek tooth #409 or 408 extracted from a 7 year old Hanovarian mare. There was a history of swelling followed eventually by drainage. A few antibiotics were used and finally SMZ pills were settled on. The owner tried this therapy for a few weeks before she was talked into extraction. I never saw this horse. I believe that if she had waited several months, this mare could have resolved this abscess, but owners do not want to wait or give antibiotics this long.

When she let me know about her change in treatment, she acknowledged to me that the horse was showing no discharge from the lump (a sign that the infection was resolving) nor was the filly having problems on the bit or chewing. The only reason she gave was that she was tired of going to the barn and hot packing the jaw.

I wasn’t surprised. People want the convenience and not the trouble when it comes to nursing care. The tooth was pulled and the abscess resolved because now there was a giant hole for drainage and the horse remained on antibiotics for 2 more weeks.

In over 67,000 floats that I have done I have seen the need in maybe 3 horses for extraction. Yet in the past decade the cry of “Pull The Tooth!” seems to become common. But just because we can do a procedure, is it always in the best interest of the horse?