Had It up to Ear: Barnum’s Inciting Attack of “Medical Care”

I hope eventually to be able to post about what’s happening with my writing, with Barnum’s training now that his mouth is no longer hurting him, and my involvement in increasing disability access in my town. But first, I’m gonna bend your ear about Barnum’s health woes for the past two months.

Part of the reason I have not been posting is because writing is so much slower for me since I’ve had to use speech software due to my wrist problem. But another reason is that I kept waiting for this particular health issue of Barnum’s to be resolved before posting about it. I’m beginning to wonder if it will ever be resolved! In fact, I’ve been writing this post for so long that it’s turned into a novella. Therefore I’ve decided to break it up into more than one post.

Here is our story…

Part I: I Should Have Listened to My Gut

I’ve posted several times recently about my search for a diagnosis — and eventual treatment — of Barnum’s mouth problems. At one point, Barnum had an appointment to get dental x-rays with a local veterinarian, but I didn’t post about what happened there, mostly because I was utterly physically and emotionally wrecked in the aftermath of that wretched appointment. Then we finally went to Veterinary Dental Services, and I was focused on updating you on the fascinating developments of Barnum’s malocclusion diagnosis and surgery.

But before we ever made it to VDS, Barnum suffered an attack of medical care from which he has not yet recovered. In fact, he has been to the vet so many times in the past three months that he developed a fear of riding in the car. Whereas he used to love trips in the van, after one vet trip too many he started to show definite signs of stress in the van: panting; a quiet, desperate whine; a face filled with anxiety. So that’s given me a new behavior to work on. Oh joy. More about that another time.

* * *

Before I was disabled by chronic illness — about twenty years ago — I trusted doctors and expected them to have answers. However, after spending several years hopping from doctor to doctor trying to get a diagnosis for my increasingly severe medical problems and being met with, at best, earnest confusion, and at worst, condescension and hostility, I approached doctors much more warily.

At the same time, I was having excellent experiences with veterinarians. Every time I took my cats to the vet, I was praised for my concern with my cats’ health and thanked for taking such good care of them. I remember saying to my friends, “I wish I could have a veterinarian as my doctor. They’re so kind. They listen so well. I wish people doctors could be more like animal doctors.”

Looking back, I realize there was another major difference between me and my cats other than our species: I was sick, and my animals were healthy. During those golden years, getting health care for my animals was straightforward. I’d bring the animal to the vet, and something simple, sensible, and straightforward would occur — an exam, a treatment, a procedure. Then it would be over.

Things changed radically when my first service dog, Jersey, had her eye problem misdiagnosed repeatedly — including by emergency and specialist vets who should have known better. General practice vets also misdiagnosed her, but at least they were honest about their limitations. All of this culminated in the loss of Jersey’s eye to glaucoma and the eventual discovery that the veterinary ophthalmologist who had screwed up the worst had falsified Jersey’s medical records, presumably to protect herself against litigation.

Then, with Gadget, I was faced with the challenge of obtaining veterinary care for a dog with chemical sensitivities, food allergies, and bad reactions to vaccines, heartworm preventative, and many other standard veterinary medications. The vet who had been so wonderful with Jersey — even buying a tonometer so that she could get monthly eye-pressure checks without going to the specialty hospital — did not believe that Gadget’s seizures were caused by his heartworm medication. I did eventually find an excellent vet for Gadget, but then I moved to the town where I now live, two hours away from Gadget’s holistic vet, and I had to search for a new vet again.

For the last six years I’ve made the rounds of most of the vets in my area, trying to find someone knowledgeable, accommodating of my disabilities, kind and gentle to my dog, and above all, really, really competent. At first, it seemed a wasteland. For example, one of the vets that people have referred me to has had multiple dogs die while they were under anesthesia, including young, healthy dogs undergoing something as routine as neutering. I also tried out two area holistic vets who did no harm, but who charged huge sums to do practically nothing. I found a vet who seemed okay, and then he retired.

* * *

Finally, about a year ago, I found Dr. Piwonka. She is open-minded, knowledgeable, competent, thorough, yet honest about her limitations, and, while Barnum does not adore her, he seems to trust her more than he trusts most vets. She is a keeper! She was stumped by Barnum’s mouth mystery, but it was also she who first suggested that I take him to Veterinary Dental Services. I deeply regret that I did not follow that advice when she first gave it. Because instead…

I thought, “An hour-and-a-half away? I have to drive across the state just to get x-rays?” Before this, I hadn’t even known that vets needed a special dental x-ray machine that was different from a regular x-ray machine. And even after I learned that, I thought, “Someone around here must have a dental x-ray machine!”

The problem was that I was imagining that whatever was wrong with Barnum’s mouth would be something really obvious that would show up on an x-ray. I also did not comprehend the kind of expertise that is necessary to properly interpret x-rays or understand how a dog’s mouth should look — what their teeth and jaws should look like.

So, when I learned that a vet who is very close by, “Dr. L, ” had recently acquired a dental x-ray machine, I thought, “Perfect!” True, Barnum saw this vet when he was a puppy, and I didn’t stick with her as our vet because I found her too conventional and not as knowledgeable as I would’ve liked, however some of my friends used her as their primary care vet and were satisfied with her, and I hadn’t heard any horror stories about her. Plus, she only needed to take the x-rays and look at them, right? That was simple, right?

Wrong, wrong, terribly wrong. First of all, Barnum needed to see Dr. Piwonka for an exam, bloodwork, and a referral before we could even make an appointment for the dental x-rays. Then we needed to wait two weeks for an opening in Dr. L’s schedule. But finally on May 24, Betsy drove Barnum to Dr. L for dental x-rays and what I was confident would be his diagnosis and surgical treatment.

I’m not going to say that everything that could’ve gone wrong did. After all, Barnum didn’t die under anesthesia, and Dr. L didn’t misdiagnose him or perform unnecessary oral surgery. Other than that… Let’s just say I regret my decision to take him there. Things went badly from the first moment: when Betsy arrived to drop off Barnum, she learned from the very grouchy vet tech that Dr. L had never seen Dr. Piwonka’s exam notes and bloodwork from the previous week. I scrambled to have Dr. Piwonka fax them over.

Because I didn’t 100 percent trust Dr. L already (red flag that I ignored!), I also sent a note with Barnum, outlining his symptoms of the past few months, including which things had improved when he was on antibiotics. I also requested that while Barnum was under anesthesia his hind toenails be trimmed, but not to bother with his front toenails because they didn’t need trimming.

I waited anxiously all morning, and when I called to check in with the vet at noon, as I’d been instructed, the assistant told me that Barnum was still “being worked on.” I thought, “Wow, he must have really needed some serious surgery.” I waited anxiously for her call.

When at last Dr. L called, she said that the x-rays of the left side of Barnum’s mouth had shown no abnormalities, so we still didn’t know what had caused the problems. However, his beard — the hair around his lips — was gunky with food, which smelled bad, so they had cut it off.

I was stunned. I had expected an obvious structural cause for the infection that Barnum had been suffering with for so long, so it was a real blow to still be in the dark about what the problem was. I was also shocked that Dr. L only took x-rays of the left side of Barnum’s mouth because, although Dr. Piwonka and I both believed the problem to be on the left side, I had still expected that once Barnum was under general anesthesia Dr. L would do a complete set of dental x-rays. (I later learned that she only took x-rays of a small portion of the left side of his mouth, which did not even include his canine teeth that turned out to be the major cause of the problem.) I also thought that Dr. L was saying that the poor state of Barnum’s beard might be the problem — as if the only issue had been bad breath, and as if, as a three-time Bouvier owner, I wouldn’t know what a dirty beard smelled like! (I spoke with her a few days later and discovered that I had misunderstood some of this. So please hold off on judgments of this doctor until I got to tell the rest of the story.)

“But,” I said, “It’s not just an issue of smell! Barnum has been having pain, lethargy, excessive drinking!…”

Dr. L said maybe the antibiotic had taken care of those problems.

“No,” I said and reiterated a point I’d made in my note: just a couple of days earlier, Barnum had yelped in pain when he scratched the left side of his face. She said maybe he needed to be on a different antibiotic or a stronger one. I countered that the antibiotic was definitely working — his breath had improved greatly, his energy was better, and he was drinking a normal amount of water again — but that we still don’t know what had caused the infection. She suggested keeping him on antibiotics another two weeks, and I agreed, but that didn’t get me any closer to a diagnosis.

I was beside myself with frustration and helplessness because I couldn’t think how we were going to find out what the problem was. Also, it seemed I had just subjected Barnum to general anesthesia and spent over $200 for a beard trim. But it was actually worse than that.

Even though I’d been instructed to wait till the end of the day to pick Barnum up, he was still gorked out and anxious, both aftereffects of the anesthesia, which worried me. Plus, when he got in the car he smeared blood droplets on his dog bed with every step; apparently they trimmed all his toenails, including the ones that were already filed short, so he’d been quicked multiple times. Of course, he also reeked of fragrance, but I had expected that because the more time a dog spends in a veterinary office, the worse he will smell of chemical products.

When we got home, my PCA and I washed him with unscented dog shampoo and baking soda to try to get the smell out of his fur; he still reeked and therefore so did my bedroom, and the fumes made me pretty sick for the next several days. But I was still glad that he was home. He continued to smell so strongly of fragrance that the next day Betsy and I shaved him (hair absorbs and retains scent, so cutting it off usually helps a lot).

While we were clipping Barnum I noticed something strange: the fragrance smell was much stronger around his head. When I leaned over his head I got particularly sick. While I was clipping the fur on his ears, I found a wet, sticky, oily residue in his ears. At first I thought I must have gotten soapsuds or water in his ears when I’d washed him, but then I realized the intense fragrance was coming from the residue on my fingers. Someone at the vet had trimmed his ear fur and used liberal amounts of a scented ear cleaner!

This was the beginning of the nightmare.

Tune in tomorrow(ish) for the ear-raising next installment!…

Barnum’s Dental Checkup Report

I have, at rough estimate, about a zillion posts in the works. Posts about my health, Barnum’s health, Barnum’s retraining as a service dog now that he’s undergone oral surgery, a review of pet health insurance, post about what’s happening with my writing, etc. I’m also going to be on BBC Radio 4 sometime this month, and I want to post about that before it happens. But what with one thing and another, I just haven’t been able to post!

So here is just about the shortest post I can wangle: an excerpt from the report of Barnum’s recheck by the veterinary dental specialist which took place on Friday, June 21. I’ve just pasted it in without any editing — except for the words in brackets, which contain explanations for the veterinary shorthand, in case you’re not familiar with it. And then at the end, I’ve included a brief summary translating some of the veterinarian-ese.

Physical Exam (11:41 am Bonnie H. Shope, VMD, Dipl. AVDC/BHS)
Subjective: BAR [bright, alert, responsive]
Temperament: friendly
Objective: Heart rate: 120/strong, Respiration: pant
Weight: 34.318 kg, 75.50 lb BCS [body condition score]: 5/9
Oral Cavity: teeth clean, gums healthy, class 2 malocclusion, gingival defect/recession at palatal aspect of 204 as before but there is no inflammation or accumulation of plaque or debris. 303 extraction site has healed. Restoratives at 304 and 404 in place with no discoloration. Rest of physical exam apparently normal.

Recommendations:
Barnum’s mouth looks great! Continue brushing his teeth daily.

Please bring Barnum back in December for an oral exam, consultation and dental radiographs under anesthesia to monitor the health of the lower canine teeth and evaluate the periodontal status of the upper left canine tooth.

In other words, Barnum’s in healthy shape, and while of course he still has the genetic defects and damage that resulted from them, where there was an abscess and damage to his gums and the roof of his mouth is clean and well healed. Where his incisor was pulled has also healed. Where his lower canines were cut and crowned looks good.

Or, the ultrashort version: “Everything looks good; the daily toothbrushing is paying off. See you in five months for x-rays.”

P.S. I think “Temperament: friendly” probably takes into consideration that he tried to lick the face off of his favorite lab tech, Jessica.

 

“Ouch!” Training: A Behavioral Approach to Brushing Barnum’s Sore Tooth

Barnum, my Bouvier service dog, recently underwent oral surgery. The veterinary dentist gave me very stern instructions that I was to brush the injured area in Barnum’s mouth every day, starting the day after surgery. She had been considering extracting one of Barnum’s upper canine teeth which was damaged on the inner side and in the surrounding gums, but she decided to spare it for now pending a good recovery in the weeks following surgery. And she said the recovery would have a great deal to do with my capability in brushing the right spot on a consistent basis.

I tend to be kind of a perfectionist/worrier/overachiever where my dog’s health is concerned, so what I heard was, “If you don’t brush exactly all the right parts of Barnum’s mouth every day, perfectly, starting right this very instant, I will yank out his tooth.”

Thus, on Wednesday, the day after Barnum’s surgery, I set out to brush Barnum’s traumatized left tooth and gums. Even though so far he was not actually letting me touch his mouth.

Even when we were just lying in bed, relaxing, every time I moved my hand toward his muzzle to try to get a peek, he moved his head away. I worked on this with him by moving my hand toward his mouth and rewarding him with a treat for not withdrawing. He got extra treats for moving toward my hand. We had progressed to him letting me touch the fur on his muzzle — as long as I didn’t touch the left side of his mouth. But the time had now come for the prescribed brushing, and I was determined to do it, no matter what.

I took him to our “grooming station,” which is my coffee table that I keep in my bathroom so I can slide it in front of the toilet and groom him whenever it’s convenient. I call this “toilet training.” It’s one of the things that I do, as a severely fatigued and chronically ill person, to get necessary dog grooming things done while conserving energy.

As a result of long and diligent effort on my part, Barnum has a very solid positive reinforcement history with sitting on this table. He is used to being groomed there and getting rewarded handsomely for it.

I got out my three dog toothbrushes and my three tubes of dog toothpaste and examined each one, trying to decide which would be the most enticing and/or the least painful.

Four dog toothbrushes and three dog toothpastes. On the left: An old-style Triple-Pet three-headed toothbrush, a mostly used tube of Petrodex poultry flavor toothpaste, and a new style but worn Triple-Pet four-headed toothbrush. In the center: A brand-new two of Petrodex beef-flavored toothpaste and a brand-new Triple-Pet four-headed toothbrush. On right: A newish tube of CET toothpaste and long-handled CET toothbrush.

Left: the good old standbys. Center: the shiny new upgrades. Right: veterinarian-recommended but not too tasty.

I don’t normally have three dog toothbrushes or three tubes of dog toothpaste, but I was worried that the bristles on my old toothbrushes had gotten too  worn so I bought a new one at the vet’s (even though they don’t have the brand I like Barnum likes) and a new tube of toothpaste because they said it was beef flavored and I used to have beef-flavored toothpaste that Gadget adored.

The kind I usually use is Petrodex poultry-flavored toothpaste (the tube on the left above), which all my dogs have liked, but which they are not as wild about as they were when I used to be able to find liver-flavored or beef-flavored toothpaste.

Unfortunately, the veterinary dental practice seems to favor CET brand toothpaste and toothbrushes, and while I’m sure they are very healthy and medically recommended, I think CET has a different concept of “beef” than I do, or more importantly, than dogs do. I let Barnum taste the new CET “beef-flavored” toothpaste (pictured above, right). Barnum was not a fan. It did not smell like beef or actually like anything (note to people with MCS: this is probably the most MCS-safe dog toothpaste I’ve found so far).

Why didn’t I use the Petrodex beef-flavored toothpaste that I dug out of my box of dog health supplies just for this special occasion? I tried to. Then I discovered it was so old that it had expired and had gotten all hard and crusty and could not even be squeezed out. (So I put it away again for the next special occasion. No, I’m kidding, I threw it out, which is why it’s not pictured above.)

In case you’re wondering why I had a disgustingly old tube of dog toothpaste, it’s because after I bought it the first time I discovered that the beef-flavored Petrodex came in horribly wasteful, expensive packaging — a big plastic pump where you get less than three ounces of toothpaste but you pay the same price as you do for a regular tube with 12 ounces or whatever. So I guess I was saving it for a special occasion and then forgot that I had it. (Let this be a lesson to you: Wear the fancy underwear you’ve been saving for a special occasion. The occasion may never happen, or if it does, it might be so far into the future that the underwear has expired and gotten crusty and become impossible to squeeze out of the tube.) However, as you can see from the picture above (center), Petrodex is now making a regular-sized tube of beef-flavored toothpaste, which we will try out today.

Anynoodle, I got Barnum up on the grooming table and tried every possible combination of toothbrushes and toothpaste, and what I discovered was this: Barnum liked the old brand of toothpaste (Petrodex poultry) the best and I like his old toothbrush (Triple-Pet EZdog) the best, although it did need to be replaced because the bristles were getting worn.

I also discovered that while he was willing to let me brush most parts of his mouth (if he was offered sufficiently high-value treats), he did not appreciate it when I pried his mouth open and scraped a scratchy old toothbrush against the infected open wound inside his mouth. No, he did not sit there compliantly for that. (Would you?) He flailed his head around trying to get away from my tool of torture.

At this point I was filled with panic that if I didn’t brush that spot right then, the veterinary dentist was going to yank that tooth out, imminently. So I went after that spot again, and Barnum tried to get away again. (To both of our credit, Barnum’s only resistance was flailing his head around to try to get the sore spot away from the brush; he didn’t growl or snap or even jump off the grooming table, which is only about a foot off the ground and which he was not leashed to).

I felt terrible. It seemed to me that all I had accomplished was hurting Barnum and confirming him in the belief that letting me touch his mouth was dangerous. I was worried that I was undoing all the years of handling training we’d done before. But what to do? The vet had said I needed to brush that area every day.

I realized that a big part of the problem was that I was approaching the situation in a state of panic, letting my emotions run rampant and not thinking clearly about training strategy. I told myself that if Barnum’s mouth needed two or three days to heal, that would probably not be the difference between him losing the tooth or not. Meanwhile, I could do things to make the task easier. I decided to “go back to kindergarten” where handling was concerned and treat him like a wild animal, clicking and treating for every small movement I made toward his mouth. I could also make sure to use lots of really high-value treats when he was on the grooming table and I brushed the other parts of his mouth. This would ensure that tooth brushing and the grooming table were not “poisoned” in his mind.

But I was still uncertain about my plan. I talked to my friend Eileen (who is a training geek blogger like me), discussing ideas with her, and then she talked to her friend Marge (an awesome trainer with a very entertaining YouTube channel), and with their help, I arrived at a plan:

1. Do lots of handling training with Barnum where I make it like a game. I touch a part of him and click and treat if he stays still. Some of the touching will be his mouth, but some will be other spots, so he’ll never know where the next touch will be, and that will help take some of the focus and anxiety off his mouth and make it more like a game. Once I started doing this, I allowed him to move body parts toward my hands and gave extra-good treats for that.

2. Use the grooming table for all his grooming, including toothbrushing, EXCEPT the ouchy parts of his mouth. Use very high-value treats and a very high rate of reinforcement for all activities on the grooming table, especially toothbrushing.

3. I would make the ouchy-spot brushing completely different from all the other toothbrushing (which should prevent “poisoning” all our other grooming and handling). For “ouchy brushing” I would use a different brush, a different toothpaste, and we would do it in a completely separate area of the house — preferably an area that we rarely use. I chose the living room couch. I use the CET toothpaste — because I figure I might as well get some use out of it — and the long-handled, soft-bristled CET toothbrush, because that design is actually ideal for the way I do this: I open his mouth on the right side and then reach the toothbrush through his mouth to scrub the inside of the left canine tooth and gum.

4. Right before I do any ouchy brushing I would give Barnum a warning word so he would feel like he has some control and awareness over what’s happening. My warning word is, “Ouch.”

5. I would use ridiculously high-value treats when brushing the ouchy spot — I chose canned cat food — which I gave him WITHOUT using a marker each time I brushed the sore spot. I was just going for classical conditioning — pairing the wildly reinforcing wet cat food with the process of brushing that tooth — and not wanting to have to worry about timing a marker to a behavior.

6. I realized I did have some control over how much the brushing hurt because the vet had given me pain medication for Barnum, which I dispensed as needed. I decided he needed it before I brushed that area! Thus, I timed the ouchy brushing for at least one hour after I gave Barnum his pain medication.

7. I decided I also needed to take my own pain medication at least one hour before I embarked on the ouchy brushing! After all, it is much easier to think straight, be patient, and reach the parts I need to reach if my own pain level is not skyhigh.

This plan has worked really well so far. I give him some good treats to get him sitting on the couch, and I put the bowl with the cat food in it right next to him to give him something to focus on. I put on nitrile gloves because things can get very messy. (The first day I put on a different brand of gloves from what I normally use, and Barnum wouldn’t touch even the really high-value treats. I realized he hated the smell of the gloves. I ditched them, and everything went fine from there.)

I started using this new protocol on Thursday and have used it everyday since. Each day that we’ve done it, it has gotten easier.

Note: Because I can’t type with my hands and because it’s harder to use Dragon with my speech impairment, it’s taken me five days to write this post. I had considered trying to include a video of me doing the “ouch” toothbrushing protocol, but I decided to just get this posted, finally. However, if there’s interest in seeing me brushing the painful area and Barnum’s mouth, let me know and I’ll make the video. (Actually, the good news is, I don’t think that area is painful anymore, so I will probably soon transition to brushing that area at the same time as the rest of his mouth.)

Barnum’s Oral Surgery: The Details

Readers of this blog know that Barnum was scheduled to have surgery at Veterinary Dental Services on Tuesday. But you don’t yet know what actually happened! So now I’ll fill you in, with pictures and everything.

I think Barnum’s whole procedure must have taken between three and four hours. Once Barnum was anesthetized, Dr. Shope conducted a more thorough exam.

She discovered that in addition to the two lower canines scraping against the upper gums and upper left canine tooth, the leftmost lower incisor was also damaging the incisor above it. Therefore, that lower incisor (the left mandibular third incisor, for those of you playing at home) would either need to be shaved down, or if that didn’t shorten it enough to keep it from interfering with the other teeth, it would be pulled. I was much less concerned about an incisor being removed than a canine tooth, because incisors are much smaller teeth (with smaller roots) than canine teeth, and there are also more incisors to carry the load if one is removed.

After the vet and her assistants examined, cleaned, and x-rayed Barnum’s whole mouth, she did decide to pull that incisor. She also performed “crown reduction” and “vital pulp therapy” on the two lower canine teeth.

In case you’re wondering what all this means in practical terms, here are some “before” and “after” pictures for you, courtesy of the good folks at VDS (thanks, Jessica!). First, here is how Barnum’s lower jaw looked before and after from the outside:

close-up of Barnum's lower front teeth, six incisors and two canine teeth

Front view of Barnum’s lower incisor and canine teeth before surgery

And here’s the same view after surgery:

but with the rightmost incisor missing and the canines about a third of the previous height, so they are just a little bit taller than the incisors.

After surgery, one incisor removed and two canines considerably shortened, then crowned.

You can see that the lower canines are much shorter than they were before. Because the part of the tooth that is alive, the pulp, extends to almost the tip of the tooth, cutting it involves use of a local painkiller, and keeping it alive requires vital pulp therapy, which is explained here:

Vital pulp therapy is performed in as close to a sterile fashion as possible. A superficial layer of the pulp is removed (“freshened”) to remove surface bacteria and unhealthy inflamed tissue. A medicated pulp dressing is then placed directly on the newly exposed pulp to stimulate healing and provide anti-bacterial properties. Finally, a protective barrier of dental composite is placed – similar to what a dentist would fill a cavity with in people.

Here is an x-ray of what the tooth looked like before surgery:

X-ray of a lower canine with four incisors next to it. The pulp of the tooth is clearly visible as a thick gray line all the way through the tooth, from top to bottom.

X-ray of lower canine and some incisors before surgery. The gray line running through the middle of the tooth is the pulp.

And below is an x-ray of how it looks now. The bright white part at the top of the tooth is where the vital pulp therapy was done.

x-ray of the same canine tooth as the previous image, but shorter and with a bright white filling in the pulp at the top of the tooth.

The bright white area is where the pulp has been “freshened.”

The good news is that the upper left canine, which Dr. Shope thought might need to be removed, is still in Barnum’s mouth. Yay! Dr. Shope said that whether Barnum keeps this tooth will depend on how well the tooth and the surrounding gums recover, and that this recovery will depend a great deal on me brushing the injured area thoroughly and frequently, starting the day after surgery. So, no pressure there. More about how I am approaching poking the outchy area with a stick brushing the traumatized area without ruining Barnum’s willingness to have his teeth brushed in an upcoming post.

So, what is this injured area of which we speak? See below….

View from below of the inside of Barnum's palate. There are three white arrows lettered A, B, and C.

The roof of Barnum’s mouth. The arrows point to areas of trauma from malocclusion.

“A” and “B” are on the left side of Barnum’s mouth. Arrows “A” and “C” point to trauma caused by the lower canines. You can see at “A” where a large area of gum is worn away, and some of the bone, too. This is likely the spot that has been infected for the last few months. “A” seems to be the spot that is the most outchy, and that is where I will really have to concentrate my brushing energies, for the next four weeks in particular. I think the damage to the tooth and the tissue at “B” was caused by the incisor that was removed.

So, that’s the physical aspect of the surgery. There was a lot going on emotionally,  too, but I hope to address that in another post.

I’ve learned a lot writing this post. I’m curious if you’ve learned anything reading it?

Thank you so much to everyone who has offered kind and supportive comments (and tweets, emails, and posts on Facebook). Even if I haven’t responded (which has been because I’ve been pretty sick and overwhelmed, not because I don’t care), I have really, really appreciated your warm wishes. I feel so much less alone when I hear from other people who care about Barnum getting well, too.

Finally! An Answer! Class 2 Malocclusion (Lower Canine Penetrating Roof of Mouth)

We went to Veterinary Dental Services today (Monday), which is just what it sounds like, a veterinary clinic that specializes in oral health. The staff was terrific, and it will be hard to cover everything I want to in this post before I pass out from exhaustion, but I’m able to dictate tonight, and I think it extremely unlikely that I’ll be able to speak or type tomorrow.

First, let me tell you about the people, because Betsy and I feel so much more confident about leaving Barnum in their care than we did with the last vet. Until today, the only person I’d spoken to there was Susan, who answered the phone when I was somewhat hysterical after having been told by Dr. L — after she’d taken x-rays of only part of Barnum’s mouth — that she couldn’t find anything wrong with him (other than a messy beard). I don’t know if I was actually crying at the time or just hopeless with frustration, despair, and anger. She told me that often people came to Veterinary Dental Services after having seen many vets who were unable to figure out what the problem was. She said somebody had just been there who had traveled three hours each direction.

She was also really helpful in terms of getting Barnum’s records from Dr. P and Dr. L. Most importantly, at that time when I was feeling so helpless and hopeless, she listened to me and gave me hope. Susan also helped me get an appointment a week earlier than we were originally scheduled for. Her own pet dog is a NEADS career-change dog so she seemed to really get it about Barnum being a service dog. (By the way, if your assistance dog is from a program, they will also do a free oral exam on them if you sign up soon.)

Then when we got there today, they were able to take us early, and after Betsy explained to Jessica, the vet tech, about my wanting to wait outside because of my MCS, they offered to do the whole thing — preliminary questions, exam, and consult — outside, which was more than I would have considered asking for. My experience with specialty hospitals is that they always want the animal to come inside. One of the best things about speaking with Jessica was how well she listened and how many notes she took about everything that has been happening with Barnum. The other best thing was that Barnum adored her. Several times he gave her many kisses, which is treatment usually reserved for Betsy and the PCAs. It’s so much easier to work with vets when Barnum likes them!

And then we met the vet, Dr. Shope. She squatted down and looked at Barnum’s mouth and said, “Oh, I think I know what the problem is.” I couldn’t believe it. He has had five or six vets look at his mouth in his adult lifetime — including three appointments with two vets which were specifically for examining his mouth — and everybody was stumped, and Dr. Shope figured it out in 10 seconds!

However, she didn’t tell us right away. My parents were there, too because they live nearby and had stopped over for a visit while we were in the area, and all four of us were like, “What is it?!” But she said she wanted to keep checking to make sure, so we stayed in suspense for a little while. (We were doing all of this outside on the cement wheelchair ramp, by the way!)

She showed us how Barnum’s teeth don’t line up right (a malocclusion) — I’ve known he had an overbite ever since Betsy brought him home after the breeder had shown this “fault” to her — but what I hadn’t ever noticed is that Barnum’s lower canines don’t meet the upper ones properly. Most particularly his left lower canine tooth goes inside the upper canine and is therefore hitting the roof of his mouth. Since this has presumably been going on since his adult teeth grew in at the age of six or seven months, he now has a hole in the roof of his mouth, which is of course painful and a breeding ground for infection. And that lower canine rubbing against the side of the upper canine has also damaged that side of that tooth and the gums in that area.

I was equal parts relieved to finally know what the problem was and horrified that Barnum had been living with this pain for so long. At one point I just wanted to burst into tears. I kept apologizing to him. It is hard not to feel like I’ve let him down, especially when I hear of other dogs who have this having caught it when they were six or twelve months old.

Extreme close-up on the left front corner of the dog's mouth showing the lower canine pressing up into the flesh on the inside of the upper canine.

Example of a class 2 malocclusion like Barnum’s. However this is NOT Barnum’s mouth.

(Above picture from http://www.veterinarydentalcenter.com/pediatric.htm.)

Of course, when we came home and I looked at his teeth, it all looked familiar. I was used to seeing his upper canine on the left side of his mouth completely hiding his lower canine from view. Indeed, I was used to pulling open his mouth to brush the lower canine because I couldn’t get to it if his mouth was closed. But I just never thought about what that tooth was doing when his mouth was shut.

The right side is not perfect either. There, too, the lower canine is not lined up properly with the one above so it is denting into the gums above, causing some erosion near the upper canine tooth. But it’s not nearly as serious as on the left side, which even after a month on antibiotics still has drool and foam and food particles on his beard that the right side does not have. And he doesn’t like to have the left side of his mouth handled.

In fact, if you look at some of the pictures in one of my previous posts about his mouth, you can see the problem. In this “Quest for a Diagnosis” post, for example, the first picture, captioned, “Barnum’s pearly whites,” is of the right side of his mouth. And you can see how the lower canine has nestled into the gumline above. The second picture shows the left side of his mouth, including that the upper canine is almost completely obscuring from view the lower canine.

Here are two pictures I took tonight to include with this post to show the problem, but given that I’d already unknowingly posted pictures that showed the problem I’m not sure if the new ones are even necessary:

Close-up of the canine teeth and two incisors on the right side of Barnum's muzzle.

Barnum’s right side. You can see how the lower canine has carved out a little space in the gum above.

 

Close-up of the front left side of Barnum's mouth.

If you look closely, you can barely see the lower canine peeking out from behind the upper, where it is causing damage inside Barnum’s mouth.

So, now the treatment plan. We were fortunate to be able to get an appointment the next day, Tuesday, the day you are now reading this. Betsy will drop off Barnum this morning and he will go under general anesthesia. A complete set of dental x-rays will be taken and his mouth will be more fully examined. The two lower canines will be cut, making them shorter so that they won’t harm the upper part of his mouth anymore. Cutting into the pulp (nerve) will require “vital pulp therapy”: a dressing on the exposed nerve, plus pain medication, and then a permanent composite crown will go over it. Our only other option for these teeth was extraction, which would eliminate the need for as much monitoring and follow-up, but I’d rather have Barnum retain some use of these teeth and also not go through the trauma of having two such large teeth removed. (The roots for all four canine teeth are incredibly long, going very deeply into the jaw, so extracting them is a big deal.)

The big question is what’s going to happen with the upper left canine — how much damage has been done to it? We won’t know till they can really get a good look at everything. If it’s damaged severely, it will have to be pulled. I really, really don’t want them to extract that tooth if they don’t have to. I’m really hoping that the damage is mostly to soft tissue which can recover when it’s not being continuously traumatized.

And after all of the treatment is decided on and performed, they will do a cleaning — to keep everything ship-shape while they’re already there and for preventative care. We will have to follow-up with x-rays on the lower teeth in six months and then once a year to make sure that the pulp is still healthy and that neither of those teeth have died as a result of the “crown shortening.”

Dr. Shope went to great lengths to explain everything to me, to answer my questions, and to include me in the whole process. The hospital even has a book they made that has photos and x-rays of previous patients’ different dental problems and how they were addressed. Dr. Shope showed me pictures of malocclusions and of crown shortening and vital pulp therapy. I think she and her assistant spent almost two hours with us between the two of them!

She also told me there would be a few days’ recovery and that she understood I would need to factor that when setting up scheduling (because Barnum would not be able to work as my service dog in his post-operative condition). This was the first time in almost 15 years as a service dog partner that I’ve had a veterinarian volunteer that kind of information and recognize that my SD’s functioning also affects my own functioning and plans. I was really impressed and grateful for her understanding of the complex role and relationship of the service dog and their human partner.

So, that’s the big update. Of course, as a devoted reader of VirtuaVet — who not infrequently finds more severe or widespread dental problems after taking radiographs than when she does the initial exam — I am really hoping there are no nasty surprises. I’m really hoping what we expect to be wrong is all there is. Fingers crossed.

The big questions hanging over my head are, “What will we be able to do with the damaged upper canine; can it be saved?” and “When all is said and done, what will all of this mean for his job as my service dog?”

I am hoping it will make working even easier and more fun for both of us — that he will be able to do things like pulling tug straps and retrieving things with more ease and joy, that the relief from pain will improve everything about his life including his work. But I don’t know what effect having truncated lower canines or especially possibly losing that big upper canine might have on his abilities to pull open and shut doors or retrieve things, etc. Will small items fall out of his mouth without the canines there to trap them? Only time will tell. For right now, I’m just focused on the surgery and the recovery and wanting him to be healthy and pain-free again.

P.S. This whole post was typed with Dragon speech-recognition software, and now that I’ve published it I see about three dozen speakos that I missed before. So if you read a sentence or phase that doesn’t quite make sense, try reading it aloud and you’ll probably figure out what I was trying to say. I’ll try to proof this piece later.

Barnum Is More like His Old Self Than He Ever Was Before

Tomorrow Betsy and I take Barnum to the dentist — a veterinary dental specialty hospital across the state from us. This is because two weeks ago, when he went under general anesthesia for dental x-rays, not only did the vet not fix the problem, the staff created some new ones (which are not related to his mouth and which I will post about another time).

Barnum has been on antibiotics (clindamycin) since May 10. The longer he’s been on it, the more he has changed. Not only have I seen changes from how he was a month or two ago — or six months ago, when I first started trying to find the cause of his bad breath — but I’m also seeing changes that hearken back to a year or two ago. I think he’s had a problem with his mouth for years, and it’s only now that I’m seeing it mostly reversed in a short amount of time that I’m realizing what a problem it was.

A few weeks ago was when things were most noticeably wrong, before he started on the clindamycin. He was lethargic — slowing down and losing heart part way through his walks, and at his worst, spending most of his time napping by himself; his breath had gone from bad to worse, and I could smell it across the room; he was drinking excessively; he was drooling excessively; and I discovered he had pain on the left side of his muzzle when he’d scratch himself there and then yelp.

So some of the changes I’ve seen in the last four weeks are what I might have expected:

  • His mouth went from smelling like an open sewer grate to smelling like nothing at all.
  • He went from excessive drooling to only rarely drooling (such as when he is waiting for treat).
  • He no longer yelps when he scratches his face and is more willing to have that side of his mouth handled.
  • He has returned to drinking his usual amount of water.
  • His energy went from sad, distant, and lethargic to bouncy, happy, and energetic.
  • His reaction to my feet moving toward his face when he is lying on the foot of my bed went from startling, growling, jumping up, and running off the bed to startling, jumping up, looking for a treat, or no visible reaction.
  • I’m not sure if he’s still having any bleeding or swelling in his mouth because I haven’t been brushing his teeth for the past month — since I don’t know what’s going on I don’t want to aggravate anything, spread any germs around, or hurt him.

However, what I did not expect were several other changes:

  • Not only is he more playful and more interested in working than he was when he got noticeably ill, but for the past two weeks he has been more energetic and mentally sharp than he has been in a very long time.
  • The type of play he is interested in has reverted back to what he used to enjoy when he was a pup. He used to love to play tug and to play fetch with a squeaky ball. When he lost interest in this type of play, I thought it was just because he had matured and grown out of it. But earlier this week, Barnum spent about two hours chewing, retrieving, and carrying around a plastic squeaky ball — including while we went on a walk — which he has never done before. I must’ve thrown that ball for him 40 times! 
  • Barnum has always been hesitant and tentative when retrieving large, bulky, or heavy items, even though he is a better retriever than Gadget was, and Gadget never seemed to have problems with these types of items. However, a few days ago, I was training Barnum to retrieve my lap desk, which is a foam pillow with a pressboard top which I use all the time and which I am having trouble manipulating due to my wrist problem. I’ve made halfhearted attempts to train a retrieve of this in the past, but it always seem to confound Barnum. But this time, once Barnum realized that I wanted him to retrieve the lap desk, he was very eagerly picking up and bringing me this big, bulky, somewhat heavy and awkward thing like he’d been doing it forever. Then, after about 10 minutes, he started to become tentative again.
  • I had always thought that Barnum was rather droolly, but in the last two weeks he’s drooled less than he has in years. However when he does drool it seems to be on the left side.
  • All Bouviers have dirty beards, but Barnum’s has been particularly so, which I blamed on the baked kibble he eats. I also blamed the kibble’s consistency for the fact that there is often a gummy paste of it around his back left molars, between his cheek and gums. But now I have noticed more food debris collecting on the left side of his beard.

 

So it seems obvious from various behavioral clues that Barnum has been having pain or discomfort in his mouth for a very long time and that being on this long course of antibiotics has relieved a lot, but not all, of that discomfort. In addition to the issues I noted above, such as the debris in his beard, the drooling, and the pain or fatigue returning after repeatedly retrieving something large, he is still showing some other problems:

  • When I give him something that requires chewing, such as a large piece of raw meat, he chews almost exclusively on the right side of his mouth.
  • In the last couple of days, he seems to be worsening slightly again — sometimes slacking a little bit more on this walk or showing a little less interest in pulling a tug cord or retrieving something large or hard.

The big question, of course, is what IS the problem? What is CAUSING the oral infection he’s had for the last few weeks? Because I am certain that now that he’s had his last clindamycin today, without fixing the root of the problem, the infection will return. And even though he’s 100 percent better than he was for the previous six months, there are still a few little hints that something is wrong.

Intro to SSL: “Sharon Sign Language”

There’s been a heck of a lot going on with both Barnum’s health (still no diagnosis, but huge improvement in his health and functioning from being on an antibiotic) and with access activism in my town. Between being so busy dealing with these issues and difficulty typing (cuz my wrists don’t like it if I type by hand, but half of the time my voice doesn’t work*, and then I can’t type by voice with Dragon, either) I haven’t been able to blog about all this intense stuff.

So, instead here’s a video I made before all the latest kerfuffle. I made it for my personal assistants, especially the new ones who don’t yet know as many of my idiosyncracies as the long-timers. I tried to think of the signs I use the most with my assistants, the things I wish most they understood. Then Betsy interpreted/narrated.

I made the video on a day I couldn’t voice because for some reason it’s easier for me to think in sign language when I can’t talk than when I can. It’s also a lot more obvious to me which signs I wish my assistants knew when I am right in the midst of wanting them to understand me. Today is a no-voice day, too, so it seemed like a good day to post the videos as well!

Here’s the description:

Sign Vocabulary & Tips for Easier Communication with Me

For my personal care assistants (PCAs), especially new hires. Please watch it with the sound on first to learn the signs. Then try watching with the sound OFF to see if you can remember the vocab!

Most of these are basic ASL (American Sign Language) signs, but a few of them are signs I’ve made up, for which I don’t know the real signs (such as for the two-way radio, computer mouse, and computer touchpad). I use a lot of V/G (visual/gestural) to communicate when my voice isn’t working. But I thought the best way to help you learn to understand me is from me.

If you want to learn real ASL, don’t learn it from me. I have a lot of bad habits, and sometimes my impairments get in the way (that was a very tired middle finger on the “K”!). Learn real ASL from a Deaf teacher!

Here’s the uncaptioned version up on youtube.

And here’s the captioned version (which I have not been able to embed in a post, so just pop over to amara to see it).

-Sharon and Barnum, the reinvigorated SD

* For those of you new to my voicing issue, due to Lyme and coinfections (other tick-borne diseases), since 2008 I’ve had an intermittent speech impairment which is apraxic in nature (relates to voluntary sounds, like speech, not to involuntary sounds, like laughter or shouting in surprise) and seems to be the mixed form of spasmodic dysphonia, ranging from so severe I can barely produce sound to so mild I just sound a bit scratchy. And other times it doesn’t affect me at all (thus the “intermittent” part of the diagnosis).

Shit People Say to People with Speech Impairments

Or, at least, these are things people (including some people I love and appreciate very much!) sometimes say to me when I . . .

Answer the phone

  • Oh my goodness! THAT doesn’t sound good!
  • Are you alright?!
  • I can’t understand you AT ALL.
  • Are you on a speakerphone? Can you just pick up?!
  • You sound AWFUL.
  • Do you have a cold?
  • I can’t hear you. Are you on a cell?

Make a Phone Call

YOU’RE BREAKING UP.

YOU’RE BREAKING UP.

CALL. BACK. ON. A. DIFFERENT. PHONE!!!

[Click]

Am at Home

  • [From another room] When are we watching the movie?
  • [From another room] Yes?
  • [From another room] What time is your phone call?
  • [Walking away] WHAT?
  • [Walking away] Where IS the dog?
  • [From several rooms away] WHAT?

Answer the Phone

Oh, did I wake you up?

No, I'm awake.

I’m sorry I woke you.

You didn't wake me. This is just how I sound.

I’ll let you go back to sleep–

No, what do you want?!

Attend a Teleconference

  • I feel really inspired by your presence.
  • It’s so brave of you to attend this. If I was like you, I don’t think I’d come to something like this.
  • You sound awful!
  • Would you rather just be silent?
  • Hey, your voice is really sexy.
  • You couldn’t speak in public though, could you? I mean, how would you talk? Do you use an interpreter or something?
  • Do you mind if I ask what’s wrong with you?

Answer the Phone

  • Ohmigod. Yourvoiceisn’tworkingrightnow?!?! OkayI’llcallbackanothertime. [click]
  • Your voice isn’t working? Wasn’t that better before? Why is it back now?
  • Do I need to get the machine? The, uh, DDT?
  • Oh honey, you sound TERRIBLE.
  • I like talking to you better when your voice is working.

Make a Phone Call

[Nervously] HELLO?

[Scared] WHO IS THIS?!

[Terrified] HOW DID YOU GET THIS NUMBER?!

[click]

Am at Home

Yup!

Yes, I understand you! I’ve already done it!

[An hour later]

You want me to make you a protein drink?

No, there isn’t one made. But I can make one now.

An hour ago? Oh! I thought you were asking if I’d let the dog out!

Attend a Teleconference

Hi. This is Mary. Who else is here?

This is Sheila.

Hi Sheila.

Hi Mary.

So I guess we’re the only two in here?

I thought there were supposed to be three people per break-out group?

Well, I guess it’s just the two of us! Let’s get started!

Answer the Phone

Hello?

Hello, is someone there?

Oh! Is . . . uh? . . . Betsy? . . . There??

I’ll just send her an email. [click]

Make a Phone Call

  • You sound AWFUL!
  • Can you speak UP?
  • Uh-oh, this sounds like a bad voice day. We can talk another time.
  • You’re having problems with your voice again? But you sounded fine last time I talked to you.
  • I CAN’T UNDERSTAND YOU!
  • Hello? Is anyone there? [click]
  • I can’t hear you! You’re holding the phone too far from your mouth!

Attend a Teleconference

I’m just so inspired by your courage.

Well, to attend something like this, I just don’t know if I’d have the courage….

I just find you really inspiring.

Answer the Phone

Hello? Hello?

Do I have the wrong number? I’m trying to reach Betsy?

Is this the number for BETSY?

IthinkIhavethewrongnumber [click]

Make a Phone Call via the Relay

[click]

[click]

[click]

[click]

Answer the Phone

Hello is Betsy there?

You can take a message?

Do. You. Have. PAPER?

And. A. PEN?

This. is. Jane. Doe. D-O-E. My. NUMBER. is. 4.1.3… 1.2.3… 4.5.6.7…

Can you read that back to me?

[click]

If you want to watch a slew of “Shit People Say” videos relating to disability, here are a bunch on youtube. My favorites are Shit People Say to Non-Verbal People, Shit Healthy People Say to Sick PeopleShit People Say to the DisabledShit People Say to Service Dog Handlers, Shit People Say to People with Disabilities, and Sh*t People Say to People with Psychological Disabilities.

P.S. I decided not to cover ground I’ve already posted on about my speech impairment.

Yes, but Why Can’t I Say It in Dogs?

As you might have picked up from my last post, things have been a bit intense. And overwhelming.

However, I have good news. I am managing to rest and sleep more and am reaching out for support. Plus, some people in town are reaching out to me. (I have been too overwhelmed to respond yet, but I will once I can figure out what the heck to say.) The overall level of despair in the house has decreased significantly!

Unfortunately, because my voice isn’t working much, and because I have been using writing and blogging to self-connect, my wrists are extra inflamed (swollen and painful). So, I’m trying to type less and YET I wanted to thank you so much for your supportive comments . . . in cats:

The words, "Thank you!" spelled with a font made up of cats. Some letters are two cats, such as the capital T, which has two cats lying on their sides, perpendicular, one with its head against the other's tummy. Other letters, such as the "u" are made of one cat, in that case, a cat curled up with its legs up, making a "u" shape.

This cat font was brought to my awareness by one of my favorite bloggers, The Bloggess and her cats, Ferris Mewler and Hunter S. Thomcat.

P.S. Not to complain, but . . ."Where is the DOG font?" spelled in cats.

Dog Dental Update, or “The Flying House Marathon”

I’m sure you’ve been waiting with bated breath (ba-dump-bump) to hear what’s happening with Barnum’s health. Here’s the update!

I spoke with the vet yesterday morning, and even though Barnum’s white blood cell count is basically normal, given how his breath smells and that she palpated swelling in an area of his gums, she believes he has an infection. So Barnum is on a two-week course of clindamycin. I agree with her assessment and am glad that it’s finally being treated.

I really like Barnum’s vet. She’s been very accommodating about my disabilities, and she answers all my questions. She was also very flexible about helping me find the cheapest option for Barnum’s medication. In my experience, antibiotics are cheaper when purchased from a drugstore than through a veterinarian. The vet wasn’t sure though, so she told me the dosage and what she charges, and then I called my pharmacy to find out how much it would cost through them. It was $29 through the pharmacy and $85 through the vet! So I asked the vet to call it in to the pharmacy. She honestly hadn’t known what the difference would be.

Meanwhile, Barnum has an appointment on Friday, May 24, for dental x-rays with a different vet — the one who has the special dental x-ray machine. That was the soonest appointment we could get. But at least the blood work is done now, which is necessary before general anesthesia. And I’ve also started submitting claims to Trupanion, his health insurance company because the costs since February — when I started pursuing this problem — will likely surpass Barnum’s deductible.

I’m actually really curious what the cause of the problem will turn out to be. I’m tempted to start a pool! Is that weird?

What are our options? Retained puppy teeth? Fractured root? Abscess?

I’m not trying to be callous. I’ve been really worried, but now that we’re finally on the road to some sort of diagnosis and treatment I’m feeling more hopeful and curious. There’s this mystery about what’s lurking beneath the gumline, and I want to knows what it is, you know? (This is probably an indicator that it’s well past time to stop my marathon of watching the last four seasons of House.)

What do you think? Anyone want to place any bets in the comments?

P.S. This is my first post that I’ve written with Dragon (speech recognition software). Hopefully I’ve caught any weird speakos. Sometimes they really entertaining, and I’m tempted to leave them in, such as when I had above, “come to my flying house marathon.”