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Hello Dr. Tucker,
I have some questions about cheek tooth extractions, more so how to avoid the process. I understand you can not give specific medical advice but I am finding it hard to advocate for my horse as my knowledge is limited in this area. I am hoping you can answer my questions and that will help me be able to have a conversation with my vet. I am up in British Columbia, Canada.
I have a 10 yr old warmblood gelding. He was diagnosed with a tooth root abscess of 308 – I believe – (it is the third premolar in on the bottom left). Right from the get go, I have been counselled to pull the tooth and as I was doing my own research, I came across your site. So, I pushed to have the horse on antibiotics for an extended period of time. The problem came when I had repeat x-rays done (that ended up being sub-par and poor quality) however, treatment was being guided by these poor x-rays. So, I was told the abscess was gone. I stopped antibiotics but within 2 weeks, my horse was uncomfortable again. I took the liberty of starting antibiotics up again (as I had some left over) and within 2 days the horse if feeling great again. I have asked my vet, if I could do a second course of antibiotics for another extended period of time but she is not in agreement. I am told the tooth needs to come out even though the abscess had cleared on the repeat x-rays. When I asked what tooth she would take out – the answer was the one that had the abscess. However, the tooth is not fractured or decayed or anything, it is a perfectly healthy tooth.
I know you can’t comment or direct this particular case but I really want to advocate for my horse so I have a few questions.
In your practice, do you ever have clients restart antibiotics and do another extended course? I read your article “Pull the Tooth” and have scoured your online information. It seems that in your experience more often than not, the tooth eventually heals it self. Do you have any other stories that you can share that would help me see how to advocate for not pulling my horse’s tooth?
Thank you so much for your time!
Kelly and Kensworth
Thank you for this question. Tooth root abscesses have not been studied scientifically, so there is no recommendation for their treatment. Removing a tooth is, in reality, lancing the abscess, allowing pus to drain into the oral cavity. Nasal discharge solved! But is there another way?
What I am about to say here is unproven, but there are no controlled studies on nasal discharges in horses and effective therapy or etiology (cause). All I can offer is observational interpretation with a hypothesis. I’ll leave it to others to prove or not prove it.
Abscesses are the body’s beautiful way of ejecting an infection. First, the infection is walled off, and second, it is pushed outside. Abscesses start with a nidus (a focus of infection), such as a wood splinter in a finger. During the process, bacteria leak out from this wall. Antibiotics kill these leaking microbes but do not remove the nidus that remains the discharge source, hence the need for long-term antibiotics. With reduced microbes, the drainage decreases and is no longer seen at the nostril; the horse swallows any released pus using a mechanism similar to that used by humans to divert sinus discharge into the oropharynx. The drainage will recur when the antibiotic is stopped before the abscess resolves the nidus.
Horses chewing without a problem and showing no negative issues with the antibiotics are often successfully treated for 30 to 90 days with a broad-spectrum oral antibiotic. While being treated, a daily lookout for digestive upsets (colic, diarrhea, off-feed) is required.
Another option is not to treat with antibiotics; the result of the abscess is the same: the infection is removed from the body. However, horse owners are unwilling to clean the nasal discharge daily for weeks, yet the horse usually doesn’t care whether it’s washed off. And they continue to chew without noticeable movement compensation.
There was a Belgian draft horse with a unilateral nasal charge from the same side as a fractured upper left cheek tooth. She was not easy to work with and was painful when I attempted to remove the tooth fractures (more than one piece from a single tooth – #209). Oral antibiotics stopped the nasal discharge but returned with antibiotic cessation. While effective during treatment, three 30-day courses proved ineffective in the long run. The sinus was flushed in between one of these periods. We all understood that removing the tooth with all the fractured pieces would be the only effective treatment. Tooth removal has a complication rate of about 50% to 70%, though this is starting to improve. However, this mare fought through IV medication and would require general anesthesia. That complication is nearly 100% in the Belgian draft breed, with the most common complication being death. We all decided to turn her out in the far field and follow “benign neglect.” These owners were conscientious about making daily observations and cleaning off the discharge.
The mares’ discharge was gone after a steady decline over two years in the nasal discharge volume. The mare never missed a meal. The mares’ teeth were examined every six months, and granulation tissue formed within the tooth fractures, thus removing the nidus of infection.
The ability of time to heal this tooth problem is the basis for a study where many horses of varying breed, age, and gender would be selected from all horses with a tooth root abscess and unilateral nasal discharge. Half would receive no treatment, and the remaining half would receive the removal of the offending tooth as a treatment. The results would be recorded at intervals for two years. At some point, before 2 years, there would be no more nasal discharge from either group. Further, I predict that some horses with the offending tooth removed would also resolve their discharge but take as long as the no-treatment group because the wrong tooth was extracted.
Unfortunately, there will never be a study like this. However, observationally, I know of no horses who died from a tooth root abscess. While cheek tooth extractions are more common, I’m sure there are an equal number of horses with tooth root abscesses where tooth extraction is not performed. But these horses will never be reported on because there is no money earned from doing nothing.
What you decide to do is between you and your vet. The information here will help in your discussion. I suggest they fully reveal their complication rates in all the horses from which they have removed that particular tooth. You can then decide between tooth removal and the experience you’re having with antibiotic therapy. Time is on your side; there is no downside to waiting.
Hi Doc T,
Thank you very much for the detailed response.
In your experience, is there a difference between a horse with an abscess in an upper cheek tooth that can drain into the sinuses and a horse with a lower cheek tooth abscess? Do the abscesses in the lower cheek teeth generally find a draining tract out the bottom?
Mandibular tooth root abscesses, in my experience, are rare. I have seen many hard jaw lumps, which usually come from trauma.
I suggested to the owner that the one draining mandibular abscess I had was a bone sequestrum from trauma. She found another dentist who wanted to pull what they believed was the infected tooth. The horse responded to broad-spectrum antibiotics on two separate occasions; however, the draining resumed a few days after they were stopped.
She took the horse from Florida to Michigan, where another equine vet/dentist scheduled her for a tooth extraction. She then shipped the horse to New Bolton (PA vet school), where they extracted the tooth without her consent. The extraction was covered with antibiotics, but the drainage returned when these were stopped. The owner never got confirmation that the tooth was infected.
She then asked her former husband, an equine vet in KY, for an opinion. He recommended a CT scan, which revealed a bone sequestrum. Surgery removed the offending piece of dead bone, and the draining abscess resolved quickly. The tooth was never infected.
Another horse was presented to me with a hard lump on the mandible that was not hot or painful. As I examined this horse that was heading to the Olympics, the Olympic veterinarian, the owner, the trainer, the rider, and the groom all watched. I asked if the horse was chewing without problems, and they said his chewing was fine. He was also fine on the bridle. The X-rays showed fluid surrounding the tooth nearest the hard mass. I suggested that the horse only needed antibiotics and the lump would resolve. Surprisingly, they agreed to this, but it could be because the horse was shipping to the Olympics in Europe, and surgery would have automatically removed the horse from this competition.
Two weeks later, the mass had not changed, and X-rays revealed the fluid’s movement to another tooth. This confirmed for me that extracting any tooth would have made a hole for drainage. However, was this fluid pus from an abscess or serum from traumatic leakage? We’ll never know because the lump resolved over the next few months and was never an issue for the following years.
I hope these stories show that I think mandibular cheek tooth root abscesses are rare and that trauma is more likely. Again, there are no compelling studies to confirm this; there are only case reports like these. I do find it interesting that two horses, both with X-ray evidence and with physical findings of swelling or drainage, did not have tooth root abscesses.