Dr. Amy “Toothy” Thomson returns to discuss diagnosing and treating maxillofacial trauma in cats. Dr. Amy Thomson and Dr. Andy Roark tackle a case involving a domestic shorthair named Malcolm, whose jaw is misaligned. Dr. Thomson explains her approach to assessing and treating jaw luxations, emphasizing the importance of physical exams and occlusion checks over skull radiographs. She also shares a simple yet effective method using a pencil to correct TMJ luxation. Tune in for valuable insights on handling similar cases and supporting pet owners through the recovery process.
You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!
LINKS
Toothy Thomson Website: https://toothythomson.ca/
ObviVet Course Referenced: https://obivet.com/product-category/certificates/
Reference Research Paper on Pencil Trick:
https://www.researchgate.net/publication/321002400_Temporomandibular_joint_luxation_in_the_cat_Diagnosis_and_management
Dr. Amy Thomson Instagram: https://www.instagram.com/toothy.thomson/
Dr. Andy Roark Charming the Angry Client Team Training Course: https://drandyroark.com/charming-the-angry-client/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Amy Thomson, often known as “toothy”, is passionate about teeth! However, it was not always this way – she started her career in small animal practice with very minimal dentistry knowledge. She was fortunate to have a great mentor in her first job where she learned a lot and her desire to learn more grew. Once she attended her first Veterinary Dental Forum in 2013, she KNEW dentistry was her passion – and became affectionately known as “Toothy Thomson”.
With time and support from her family, friends, collogues and a big ‘shove’ from her mentor she applied for a dentistry and oral surgery residency and was overjoyed when she matched at the University of Wisconsin-Madison. During her residency her passion grew not only for dentistry, but also for teaching. And because life is always full of surprises Dr. Thomson found herself at a crossroad in 2020 in the early stages of the pandemic – so she started her own mobile dentistry practice!
In addition to with working alongside small animal general practice teams, she also became very active online sharing her knowledge. It has always been important for her to share as much as she can, given it took hundreds of hours and thousands of dollars to obtain the knowledge she did while in general practice. Knowledge she wants to see all veterinary teams have!
EPISODE TRANSCRIPT
Dr. Andy Roark: Welcome everybody to the Cone of Shane veterinary podcast. I am your host Dr. Andy Roark guys, I got a good one for you. We’re doing some maxillofacial trauma today. We have got a rowdy kitty cat whose jaw is now out of alignment and I’m thinking about doing some skull rads but I’ll be honest. I don’t tend to see a whole lot when I do skull rads And I think Amy may have a better way.
So anyway, we’re going to assess this patient. We’re gonna get into this case We’re gonna fix this cat and we’re gonna roll on with our day guys. Let’s get into this
Kelsey Beth Carpenter: (singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark: Welcome to the podcast, Dr. Amy Thomson thanks for being here.
Dr. Amy Thomson: Yeah, thank you so much for having me.
Dr. Andy Roark: It is my pleasure. I always enjoy having you on the podcast. You are such you’re such a positive person and you are just, your enthusiasm for dentistry is just so obvious. And I just, I, you always get me excited about dentistry when I talk to you.
And so for those who don’t know you, You are a boarded veterinary dentist. You were in general practice for a number of years and then went back and got your and got your specialty ironed out and you got boarded and now you are a full time dentist. Friends call you Toothy Thomson
Dr. Amy Thomson: They do, yeah.
Dr. Andy Roark: Which is a great it’s a great and terrible nickname, I think,
Dr. Amy Thomson: Yeah, I love it. I’ve I answer to Toothy now. I’m like, Amy, Toothy, it’s the same.
Dr. Andy Roark: That’s good. I love it. You’re just like that’s what, it’s who I am. I’m comfortable my dental skin.
Dr. Amy Thomson: I am who I am.
Dr. Andy Roark: Yeah, that’s it. Cool. I’ve got I’ve got a case for you that I want to talk through. So I’ve got this four year old male neutered domestic short hair and mom has come home
from work. And it’s the boys. So there’s three of them. And but this is Malcolm who’s come to see me. And when mom comes home, Malcolm, the first thing she notices, he’s drooling. He’s just got big saliva strands coming out of his mouth. And then when she looked at him, it’s almost like he’s holding his jaw over to the side.
And so when I’m looking at his lower jaw, his mandible is clearly shifted to the left so to his left. And so yeah, jaw is shifted over to the side. There’s drool. Not as uncomfortable as I thought he would be. He’s not really letting me mess with his face, but honestly, I’m not sure he’d let me mess with his face very much when his jaw was where it was supposed to be.
Dr. Amy Thomson: Okay.
Dr. Andy Roark: Before I wade into this, so I’ve I’m, I’ve got this cat. I’m, my, my tentative plan here before I reach out to you is, I was gonna sedate him and take some skull rads and things like that. But then I’m also like, honestly, between you and me, what am I gonna what am I gonna see with these skull rads?
Is this gonna be am I going to do like I just, let’s be honest, I don’t know a lot of vets that get a lot of information on skull rads and now some of them do for obvious reasons, but you get, you should have kept my point here. And I want to be a good steward of their resources.
I want to get this cat pain free as quickly as possible. Before I get my hands in here, Amy, how do you treat this? What are you looking for? How would you game plan this? How would you advise the pet owner? What kind of diagnostics are you even reaching for here?
Dr. Amy Thomson: Yeah. Yeah. No, I love that. I’m sorry to hear about Malcolm. Obviously super stressful, so I think some sedation will be helpful. To be able to do a a complete physical exam, but also an oral exam. And I agree. So I think oftentimes when there’s any sort of potential trauma, although it sounds like they came home indoor cats, no, no known trauma, but who knows what the boys get up to when we’re not home.
Dr. Andy Roark: Sure. There’s, I’m sure there’s tipped over plants and, mail on the floor. I’m sure that every day is an, as a discovery when mom comes home.
Dr. Amy Thomson: Yeah, something’s happening when she’s at work yeah, so anytime I have what I would group together as maxillofacial trauma I really want to, as much as we want to fix him and figure out what’s going wrong I find sometimes, whether it’s this or whether we know there was a trauma, like a bit by another cat or another dog or, Heaven forbid, like a hit by a car or something like that.
I think the first thing we want to do is jump to diagnostics like say skull rads and okay, what’s the problem? But I would encourage everyone, and this is something that’s taken me years to figure out in my dentistry or surgery residency and after, is just take an inventory of what do things look like from a distance?
What is happening, and you’ve already done it without maybe even, realizing or subconsciously knowing, but there’s asymmetry and that’s really important, that you’ve noticed that the lower jaw is off the hedge bingo, right there, that’s some asymmetry, and that’s something new, that you’ve noticed because you’ve seen this pet before, or perhaps you haven’t seen before, but you’re like, this is strange that it’s so asymmetrical, And probably just following up with the owner to be like, they’re not normally off to the side.
And they would agree and say, okay, something’s awry there. And so then I would focus on delving more into that. maxillofacial or oral exam. And so when there’s trauma, definitely looking for any asymmetry. So I do like a pat along the head, around the jaw, and just like looking for any obvious asymmetry just by looking, then by palpating.
And then often what I’ll do is without opening the mouth, especially if there’s any sort of trauma that could be painful I try and support keeping the mouth open closed and lift their lips up so that I can see how the teeth align. And so I will bring it back to, basics or foundations of what is the occlusion?
So how are these teeth line up with one another? And one, is it normal? And two, if it’s abnormal, is this what the pet looked like, quote unquote, pre trauma. We all know, maybe more so in dogs than little kitty cats, but we also know that there’s a lot of dogs walking around with malocclusions and jaws not totally lined up normally.
So that is something to consider. But let’s just say, I don’t know if you said, but you didn’t say it was an exotic pet. So I’m going to assume that Malcolm is a domestic shorthair. Okay, great. I’m picturing he’s black. I don’t know why.
Dr. Andy Roark: He’s a tabby.
Dr. Amy Thomson: He is. And so he’s a, what we would call mesocephalic. So not long nosed, always cephalic or smushy face, brachycephalic.
And for the most part, these cats have what we consider normal occlusion. And so that occlusion, just as a reminder to everyone listening is that the maxillary upper incisors sit just slightly in front of the lower incisors and they just, the lower incisors, just, Hang out on the back side of the upper incisors on something called the cingulum, which is just a fun Scrabble word for any players there.
And then we have a interdigitation of the canines. So the lower mandibular canines will sit in front of the maxillary canines and then we have the premolars, both for cats and dogs, that sort of interdigitate without touching. And then the main caracal or max ray, fourth premolar sits on the outside of the first mandibular molar.
So those are like the four things to check for occlusion. And so I suspect what we’ll see with Malcolm, whether pre or post sedation, depending on how he’s feeling, is that we’ll notice. that his left canine is no longer sitting in that nice interdigitation, and it’s really shifted over, and potentially, depending on how far it’s shifted, that right canine could be hitting the upper incisors and then not allowing us to fully close. so I’m suspecting that’s what we’ll see.
Dr. Andy Roark: Yeah, sure. Okay. So all that makes sense. I do like that. Just as an open, open sort of position how common is it for pets to have sort of lateral occlusions problems, underbites and overbites. I definitely, you see those that, they’re obvious.
Do you often see a sort of I don’t know, a as asymmetry, that’s not under overbite but a lateral offset. How often do you come across that?
Dr. Amy Thomson: Almost never, unless there’s been trauma.
Dr. Andy Roark: Okay, that, that was, that’s what I was getting at. I was
Dr. Amy Thomson: yeah.
Dr. Andy Roark: looked at a lot, okay. That, woo, there for a second I was like, have I been not seeing, okay, good. Oh, wow.
Dr. Amy Thomson: That would be the, like the, so while there’s four main areas to check. They’re all, are four main malocclusions. So just briefly class one is skeletally normal, a tooth or two out of the way. Class two would be what looks like the maxilla is longer than the mandible, and then this sort of Pretty common, although I would argue with nomenclature, how I feel that, not normal, but very common in a lot of brachycephalics, is that class three, so the mandible looks longer than the maxilla and then class four is when you have a difference from one quadrant to the other.
So we have either a rostral caudal difference between one maxilla to the other, one mandible to the other, or if we have a shift from one side to the other. And so generally speaking, to get that class four malocclusion, there either needs to be some sort of trauma and you’re being presented with the pet post trauma, or potentially if there’s been a trauma in the past during growth or development we can sometimes see pets that will have different length mandibles or maxillas if they’ve had trauma when they were like a young growing kitten or puppy.
Dr. Andy Roark: That makes sense. Talk, talk to me a bit about imaging and the interface of imaging with occlusion. If that’s something that we care about.
Dr. Amy Thomson: Yeah, for sure. I. Basically never take skull rads. And the reason being I understand why it’s done. We’re just trying to find the problem so is there a fracture? Is there something luxated things like that? But if we go back to Malcolm, I would argue that we could probably localize where we think the lesion is and the type of lesion we think it is based on the our overall assessment externally as well as external palpation and then looking at that occlusion So if we go back to malcolm, we’ve got shift of his mandible to his left We’ve got we can open the mouth.
We can’t quite fully close it And the mandibles are moving together as one. So unlike you and I, we have one complete mandible. Our cats and dogs, as you all know, have two mandibles, but they meet at a joint as the front. So they still work as one unit. And so they’re moving, they’re shifted to that side and I can’t correct it, which is important.
So in addition to having that drift to the left side, I’ve got what you could call like an open bite or unable to fully close his mouth and I can’t push him into normal occlusion, even say if we’ve heavily sedated him. And so that’s got my list of differentials is getting a lot smaller. I’m starting to think, okay there’s no there’s no, between his two jaws.
They’re moving together. I can’t move them separately and I should circle back and say that I didn’t palpate anything on the outside along the ventral cortex. I didn’t feel any incongruity, any crepitus. So I would say fractures pretty low on my list. And then the fact that I do have drift to the side and can’t fully close.
I’m going to say that I’m about 90 percent certain that this is a rostral right TMJ luxation. And that’s why it’s luxated forward and then shifts away from the luxation. And then because this joint is luxated, and because of that malocclusion, I can’t fully close his mouth. So I would feel pretty confident with that assessment of Malcolm.
Dr. Andy Roark: That’s amazing. Yeah, that’s yeah, that’s amazing. I love it. I I have learned a new toy that I need to play with, which is thinking and looking a lot more at jaw position in these cases, as opposed to going to, I always take x rays in. And try to look and it never works. And so yeah, this this totally makes sense.
Okay, cool. Talk to me a little bit about sort of the communication with mom and sort of expectation setting here. If we do have a TMJ luxation, what do you, how do you how do you prime them for recovery? How do you set expectations on what life with Malcolm is going to be like in the short and longer term?
Dr. Amy Thomson: Yeah. Yeah. Great question. Yeah. So again, like I said, I’m about 90 percent certain. We can’t be 100%. So I think being very honest with owners skull x-rays are really hard to position in a way to get a good view of the TMJ. Like I’ve read the studies. It’s really hard to do unless you have an anesthetized patient.
And even then are we super comfortable saying for sure what’s going on? I would argue that. Unless we get the perfect projection and we can see that there is that luxation, it’s hard to say for sure. DV view, but like a lateral view, there’s so much superimposition. And I’ve personally seen where we thought there was a fracture, like the RDVM, and maybe even a radiologist, maybe they thought there was a fracture, but couldn’t say for sure with a skull x ray and it turned out that there wasn’t a fracture there.
I think As best we can, just let the owner know, I think in this specific case I was, working in my dentistry or surgery land, and I was called in a case similar to this by the ER doctor being like, what do I do? And I just said, listen, imaging is going to be helpful.
If we can get the perfect projection to show and confirm my high suspicion for a luxation Then we’ll feel that much better with treatment. However, in a young cat with no significant trauma, so there’s no other wounds, this malocclusion, the not being able to put them into normal occlusion. I like if I always tell owners if I’m not a gambler, but if I was, I would put me putting money down on a rostral right TMJ luxation.
And the great thing about this, especially in cats, is all that you need is heavy sedation and a number two pencil to reduce this luxation. So we can know pretty quickly if if I’m right. And That’s a nice thing to have in your back pocket is the pencil trick. And myself through the through the vet or in your, the ER vet or in your case with Malcolm, just say, based on what I’m palpating, what I’m seeing, it’s really localizing the injury to this right TMJ.
And with heavy sedation, I think we can put this I feel pretty confident we can get this back into place. And so the, there’s a paper on this and I can send it to you for the resources. And I have a little video actually of it that I post on my Instagram. But in any case, what we use is we use a pencil because we want something that’s not too hard because we don’t want to damage the teeth.
And then what we do is we put the pencil between the main chewing tooth on the side that’s luxated. And as we put pressure with our, so my right hand, I’ve got the pencil between the two carnax seals on the right side, and then with my left hand, I’m putting pressure to close the jaw. I rotate the pencil back because I want to push the jaw back and into place.
And it, it honestly takes like maybe 20, 30 seconds when you twist the jaw. I was going to say toothbrush. I’m always talking about toothbrush in the mouth. The pencil, it’s going to push the jaw down so that it can get under what we call the articular eminence, which is the front part of the socket joint.
There, like on the temporal bone, push it down so it can get underneath and pop back into place. And once you’ve pushed the mouth and twisted, then you let go, and it does, it looks like a bit of a magic trick, but then all of a sudden you can fully close that mouth and all those teeth are lined up perfectly.
And so in an acute setting, Oftentimes we don’t need to do anything other than getting it back in place. So I would use pain medication and ask for some softer food because he’s going to be sore from being stuck open that long. But generally speaking most of them if it is traumatic or they just got tousled or hit and nothing’s fractured it, it won’t recur.
If there’s like a confirmation issue, which we wouldn’t know without, say, a CT scan it may re-luxate. And I’ll tell owners that, if they’re like, you know what? I’m in for the number two pencil trick. Let’s not do imaging. I would just let them know if it recurs again.
I would be concerned that there might be something anatomically wrong and at that point we could image.
Dr. Andy Roark: yeah that I think that makes a lot of sense and setting up for the future But yeah, talk to him about where they are. Hey, that’s awesome. Amy. This has been super helpful. I really appreciate it this feel I feel like I got some guidance here. I feel I think I know what we got to try to do yeah, this makes a lot of sense. Are there, besides the pencil video which I would love to link up in the show notes I’m sure
Dr. Amy Thomson: Yeah.
Dr. Andy Roark: Are there other resources that you really a big fan of?
Dr. Amy Thomson: Does it sound weird if I say I like the resources I’ve created?
Dr. Andy Roark: No, it does not sound no. What do you got?
Dr. Amy Thomson: There’s a few different resources. I would say a free resource that’s open to anyone and everyone, whether they’re veterinary professionals or pet parents. I do a lot of education just through fun little posts and reels on Instagram.
I’m Toothy.Thomson that’s what they call me. The pencil trick is in there, but I’ll send it to you directly so you can link it here. And then for veterinary professionals that are looking for some more information, whether it’s on periodontal disease taking x-rays I have a brand new cat class, so it’s three hours of RACE approved dentistry CE just on cats, because cats are not small dogs, they’re special creatures.
Obivet.com. Or it might be dot CA. Yeah, we’re in Canada. So dot CA. And so I have four different CE courses there. It’s on demand. So you’ll have it for two years and you can go through all the videos and lectures. So that’s been a been a labor of love that I was fortunate to get to do and put together with a friend and colleague who’s a radiologist.
So there’s some other veterinarians and different topics on there as well. And then last but certainly not least, I also am a guide for something called VetHive. So it’s a by subscription veterinary community. So we put on put out some articles and some CE weekly, but it’s also a discussion group.
So it’s a very safe space. We’ll say judgment free, truly where you can post cases and get feedback. Sometimes real time, depending on who’s available. It’s not uncommon I’ve gotten a, Help me, this pet’s under anesthesia and it just works out that I’m at home and can call them. I won’t guarantee that.
But there’s over 60 guides in 27 different topics or specialties. So there’s three dentists, oral surgeons, including myself, but we’ve got the whole gamut of things. And so I do a lot of resources and training and support there as well.
Dr. Andy Roark: That’s awesome. That’s just great. Alright, cool. Guys, I’ll link all that up in the show notes. Thanks for being here, everybody. Thanks, Amy, for coming along and doing this case with me.
Dr. Amy Thomson: Yeah.
Dr. Andy Roark: Take
care of yourselves.
Thanks for having
Dr. Amy Thomson: me on! It was great to discuss little Malcolm.
Dr. Andy Roark: Oh, I always love having you here. Alright, take care, everybody.
Dr. Amy Thomson: Thanks.
Dr. Andy Roark: And that is our episode guys, that’s what I got for you. I hope you enjoyed it. Thanks for being here Thanks to amy for being here and lending her guidance on this case guys If you enjoy the episode leave me an honest review wherever you get your podcast, I love doing it I love putting these episodes out, but this is how people find us.
So anyway, it always means a ton. Take care of yourselves everybody. I’ll talk to you later. Bye.
