Going Toothless

Sometimes battling a progressive, painful dental disease requires a drastic approach.

He’s my special one,” I said as I led Loopy, my 16-year-old Thoroughbred, into a stall for his annual dental exam in 2014.

We had already been through so much with this amazing and resilient horse. He had a bone sequestrum0 removed in 2006 (“Loopy’s Long Winter,” Case Report, EQUUS 353) and a bone infection on the face called a suture line periostitis in 2009 (“Apart at the Seams,” Case Report, EQUUS 389). Now our third contribution to EQUUS was about to get underway.

Loopy, I was told, had a dental disease called equine odontoclastic tooth resorption and hypercementosis (EOTRH). Recognized in this country only within the last 10 years, EOTRH affects all of the structures (cementum, dentin, enamel, pulp and bone)—that make up the incisors and canine teeth. The horse’s body breaks down and dissolves the cementum around the base of the teeth, causing inflammation and resorption. Even though the teeth decay severely as a result of this process, an overgrowth of the cementum (hypercementosis) may occur, giving the teeth a bulbous, cauliflower-like appearance.

As the teeth degrade, they often fracture, and infections may develop in the surrounding gum tissue (periodontitis) and in the underlying bone socket as well as in the soft tissue on the interior of the teeth (endodontic disease). These fractures and infections can be very painful, and ulcers and drainage tracts may form through the gums. The causes of EOTRH are unknown, and it develops mainly in older horses.

I listened carefully, baffled by the seriousness of the diagnosis. The disease is slow moving and it is also progressive—in time, all of Loopy’s front teeth would be affected, if they weren’t already. There was no way to stop the steady degradation of the incisors. Apparently, Loopy was already experiencing significant pain, and it would only grow worse. Loopy’s last dental exam had been about a year ago, so all of this was a relatively new development—still, I felt a little guilty for not having noticed anything amiss. Admittedly, though, Loop has never liked to have his mouth handled. He twitches and protests until you let him be.

I asked what could be done, and I was floored by the response: surgically extract all of Loopy’s front teeth.

An extreme measure

My mind spun: Can you even do that? How will Loopy eat? How will he graze? How will he defend himself in a herd? I couldn’t wrap my head around a horse this young with no front teeth. But I was assured that horses who have undergone this procedure adapt quickly and soon learn to pick up their feed and even crop grass with their lips, tongue and gums. In the end, he’d be no worse off than horses with healthy, intact front teeth.

Fortunately, I had a little bit of time to think. This disease advances slowly. It was not like I had to rush Loopy off for emergency surgery that afternoon.

Because Loopy is a nervous horse and very attached to his pasturemates, I initially thought it would be best to have his teeth extracted right on our farm. But that would require a veterinarian with a portable x-ray machine powerful enough to get films of the head. The veterinarian would also need to be skilled enough with radiology to confirm the diagnosis and assess the damage in each tooth, and then he or she would need to be comfortable performing multiple, possibly complex tooth extractions in the field.

After speaking with several veterinarians, I decided it would be best to haul Loopy the two-and-a-half hours to the Cornell University Hospital for Animals in Ithaca, New York, to have the procedure done by Ed Earley, DVM, AVDC/Eq, a veterinary dental surgeon with a great deal of knowledge and experience in dental cases. Earley’s practice is located in Pennsylvania, but he travels to Cornell to perform surgeries every other week.

I made the appointment, but we still had a few weeks to wait. I used that time to learn as much as I could about EOTRH. The disease usually begins in the corner incisors and spreads inward to the central teeth. EOTRH’s first signs are redness, swelling and recession in the gums around the affected teeth. At first, the horse may not be bothered, and as long as he remains comfortable, a veterinarian may recommend simply monitoring the case. But as the disease progresses, the horse will develop more serious complications, such as ulcers in the gums and fistulae (draining tracts) with purulent discharge. Antibiotics and anti-inflammatory drugs may provide some relief, and early on, a veterinarian may opt to remove only one or two more severely affected teeth, but over time, all are likely to need to be taken out. Removing all of the incisors at once is more extreme, but in advanced cases, it is the best way to relieve the pain. 

One of the more upsetting things I learned was that the condition can become very painful as it advances. Horses with EOTRH may be reluctant to accept carrots or apples, and they often become head shy or start refusing the bit. They may begin headshaking, and if they have difficulty cropping grass or picking up hay or feed, they lose weight.

Loopy hadn’t shown any signs of discomfort—but he can be very stoic, and it bothered me to think he’d just been soldiering on when I could have helped him. I did make some management changes that I hoped would make him more comfortable while we waited to go to Cornell. I secured enough soft, second-cutting hay to feed him that exclusively, and he was on grass during his turnouts, so he was able to eat softer forage all day.

Extracting teeth

When Loopy finally arrived at Cornell, he was settled into a big, sterile stall while a veterinary student performed his intake examination. Then he was taken for x-rays—these would show how many teeth were infected as well as how badly their internal structures and the surrounding bony sockets had been compromised. This information, in turn, would dictate the extent of the surgery.

Earley led me to a monitor to show me Loopy’s x-rays. The bad news was that the images confirmed what we already suspected: The disease had spread through all of his front teeth, and they would need to be removed. The good news was that Earley had performed this surgery many times. With nerve blocks, it can be done while the horse is standing, and typically there are very few complications. Loopy’s prognosis was excellent.

I asked what seemed like a million questions, and Earley patiently answered every one. We covered every aspect of the surgery as well as what to expect in Loopy’s recovery. As we wrapped up our conversation, I was left with a feeling of confidence that I had made the right decision and chosen the best-qualified veterinarian to perform the surgery.

I hated leaving Loopy, but I had four other horses to tend to at home. Earley told me he would call by 5 p.m., when the surgery was complete. When the call finally came through at 7 p.m., I was definitely worried and pacing. But Earley said Loopy had been an excellent patient and was recovering nicely—it had simply taken longer than expected to remove all of the infected material. He explained that in addition to extracting each tooth, he had removed some of the underlying bone to ensure all the infection was cleared and to allow the gums to heal over a smoother surface.

Loopy would stay at the hospital for two nights, and I could expect updates from the students and veterinarians on staff twice each day until he was discharged.

Back at the farm, everything was eerily quiet. My other horses were definitely not the same. Loopy’s absence proved that he is the heart of our farm.

Settling in back home

When I arrived at Cornell to bring my boy home, a student was leading Loopy out, and all I could see was his backlit silhouette as he walked toward me. Still, I would know him anywhere.

But when Loopy came closer, I was taken aback by his appearance. He was sedated yet nervous, and his tongue was lolling out of his mouth. He was sweaty, and he had drool on his chest. I thought I had made a huge mistake. My handsome and refined Thoroughbred, who had the face of a horse in a vintage painting, looked all wrong.

I did my best to calm down and quickly loaded Loopy and headed home. For the whole drive, I kept reminding myself that he had been in pain and that the surgery had to be done. Yet I worried about what kind of life he would have now. How could he eat? Would he always be covered in drool? Would his tongue hang out all of the time? Would he be miserable?

As I unloaded Loopy, we were met by immediate calls from his herd inside the barn. I put Loop into the run by the stalls, and he greeted his friends, took a drink of water, then wandered outside to roll. When he came back he bypassed the soaked hay for the regular hay and relaxed in his stall. My fears were unfounded. He didn’t seem miserable at all.

Loopy proved to be a model patient when it came to taking the prescribed course of anti-inflammatory medications and antibiotics, but he had decidedly different feelings about the rest of his care. I was supposed to be rinsing the sutures each day with a syringe of warm water, but Loop made it perfectly clear that was not going to happen.

I emailed Earley about this problem and sent him photos of how the sutures looked. He answered right away to assure me that Loop should heal fine and rapidly, even without the rinsing. And he was right. Within a few weeks, the surgical sites were closed and Loopy returned to his normal life, minus his front teeth.

Making adjustments

It has now been almost two years since the surgery, and although the tip of Loopy’s tongue sometimes sticks out—a common aftereffect of this procedure—no one would ever know that all of his incisors and canine teeth have been removed. However, I did have to review nearly every aspect of his management and make some adjustments. Here are some of the questions I had to address:

Does his bit fit? Although I had been told that I could continue using the same bit, Loopy didn’t seem comfortable with his old snaffle. His front teeth are no longer there to hold his tongue back and, to me at least, his tongue seemed more prominent. I tried many but finally settled on a bit with a mouthpiece curved specifically to allow for a large amount of tongue clearance.

Can he defend himself in a herd? A horse without front teeth might not be able to bite to defend himself when changes in the herd require the establishment of a new hierarchy. Luckily, this was not an issue for Loopy because he has been with the same pasturemates for years, and they all get along.

Can he graze? It can take a little time for horses with no incisors to learn to crop grass, but they can do it. Loopy had his surgery in June, a prime grazing time here in the Northeast, and I took him out on the lead and picked grass for him until he got the hang of it. He would get frustrated trying to tear off grass on his own, but he kept trying. It seemed to help him to have longer grass—six to 10 inches high—and he learned to graze by using the roof of his mouth and his tongue to rip it off. Now he grazes just as well as my other horses.

Can he groom his buddies? Loopy has very close relationships with the horses in his pasture, and I have observed that he misses out on the mutual grooming sessions because he is unable to return the favor when they nibble at his neck, back and withers.

Can he scratch himself? During shedding season and when the insects are out, I have noticed that Loopy is not able to scratch the itchy spots on his sides, and he now engages me to do so. He has a specific approach where he basically shows me where it itches, and I curry him until he walks away. He had always done some version of this, but now it happens more often since he can no longer do it himself.

How will he eat hay and grain? Loopy now dunks his hay in his water when he is in his stall, and when he eats grain it will spill from his mouth and build up very quickly on the sides of the bucket. I clean the buckets daily, but it could be an issue with insects over the summer. He needs a new bucket of water sometimes twice per day while he is in his stall because of the amount of hay in it. He also takes twice as long to eat his grain, even though I soak it into a mash for him.

For me, the decision to remove Loopy’s teeth was the right one. EOTRH is simply no longer a worry. He was clearly more comfortable without the pain in his teeth as soon as I brought him home, and within two weeks of the surgery I was riding him again (in a hackamore until we had figured out the bit situation). Today he is still my smart, steady and athletic trail, dressage and jumping partner. Just sometimes he sticks his tongue out.

This article first appeared in EQUUS issue #463, April 2016. 




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