Veterinary Medical Case Study: “Chester”

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Patient Case Study: “Chester”

  • Species: Canine
  • Breed: Yorkshire Terrier
  • Sex/Status: MN (Male Neutered)
  • Age: 11 years

Presenting Complaint:

Chester visited for a routine wellness check on 1/2/2025, where Grade III dental disease was noted. A dental cleaning (COHAT) with extractions was recommended to address periodontal disease.

01/09/2025 Surgery – COHAT + Extractions

Pre-Surgical Findings:

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  • Bloodwork (1/3/2025) – Senior Panel:
    • Elevated Alkp, Chol, Triglycerides, and PSL
    • T4 (thyroid hormone) was low – Recommended Thyroid confirmation panel (SA390 $417)
    • Heartworm Test: Negative
    • Urinalysis: Isosthenuric with 3+ protein levels
  • Anesthesia: See anesthesia log for pre-medication, induction, and intra-operative monitoring.

Oral Examination Findings:

  • Dental Grade: III/IV
  • Periodontal Pockets Identified:
    • 103: 5mm
    • 104: 7mm
    • 107: 6mm
    • 202: 5mm
  • Mobile Teeth Identified:
    • 109, 202, 209, 404, 310
  • Dental Radiograph Findings:
    • Missing teeth: 105, 205, 405, 411, 305
    • Root resorption: 106, 206, 306, 406
    • Abscesses present: 209, 310, 109
    • Loose symphysis (jaw instability)

Extractions Performed:

The following teeth were removed due to mobility, deep pockets, and abscess formation:

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  • 109 – Mobile with pocket around root, abscess present
  • 202 – Mobile with a 5mm periodontal pocket
  • 209 – Abscessed
  • 310 – Abscessed, mobile
  • 404 – Mobility

Surgical Notes:

  • Affected teeth were extracted using standard dental techniques.
  • Three gingival flaps were created for proper closure.
  • Areas of abscessation were cleaned and debrided.
  • Post-extraction radiographs confirmed complete root removal.
  • Nerve Blocks Administered:
    • Caudal mandibular block: 2
    • Inferior alveolar nerve block: 2

Post-Surgical Recovery:

  • Recovery Status: Unremarkable
  • Medications Administered (Injectable):
    • Hydromorphone 0.4ml IV at 2:00 PM
    • Rimadyl 0.64ml SQ at 1:00 PM

Go-Home Medications:

  • Carprofen (25mg, pain relief & anti-inflammatory):
    • Give ½ tablet by mouth twice daily (every 12 hours) for 5-7 days
    • Give with food – Stop if vomiting, diarrhea, or black stool occurs
    • Start on 1/10/2025, anytime after 1 PM
  • Gabapentin (100mg, nerve pain management):
    • Give 1 capsule by mouth twice daily (every 12 hours) for 7 days

Post-Operative Care Plan:

  • Diet: Canned food only for 10 days
  • Follow-Up Appointments:
    • Recheck in 3 days
    • Recheck in 10 days

Two-Week Recheck (1/23/2025):

  • Extraction sites were healing well.
  • No complications, swelling, or signs of infection.
  • Chester recovered without issues.

Summary:

Chester, an 11-year-old Yorkie, came in for a routine check-up, where the vet discovered moderate to severe dental disease. A dental cleaning and extractions were recommended to remove damaged and infected teeth.

On January 9, 2025, Chester underwent a COHAT (Comprehensive Oral Health Assessment and Treatment). The vet found several infected, mobile, and abscessed teeth, as well as some jaw instability. Five teeth (109, 202, 209, 310, and 404) were removed to eliminate infection and pain.

Chester recovered smoothly from anesthesia and was sent home with pain medication and soft food to aid healing.

At his two-week follow-up (January 23, 2025), Chester’s mouth was healing properly, and he showed no signs of pain or complications.

This case highlights the importance of regular dental checkups to catch dental disease early before it causes infections, pain, or jaw issues. Chester’s owner should continue routine dental care, follow-ups, and possibly using dental chews or a special diet to prevent further dental disease.

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