5. Coughing in the 15-year-old dog

If heart disease is diagnosed, the owner has to give the medicine diligently if she wants her beloved old dog to live long. Otherwise, the coughing recurs and the dog dies from heart failure.

Effective dosage is the key to success. This is done by observation of no coughing with minimal dosage and regular timing of medication. You cannot just forget one day or two.

An example of effective dosage is this 15-year-old dog.
Every 2 weeks, the lady would come for the medication which is:

Body weight 19 kg.
Vetmedin 5mg x 14 (1/2 twice a day)
Fortekor 20mg x7 (1/2 once a day)
Fursemide 40mg  x28 (1 twice a day).

The dog is active and she is so happy.

-------------------


Treatment
1. Vetmedin. Congestive heart failure originating from valvular insufficiency or dilated cardiomyopathy in dogs.
2. Fortekor. Heart failure due to mitral regurgitation (endocardiosis) and dilated cardiomyopathy and chronic kidney disease in dog.
 Frusemide 1-4mg/kg orally to clear fluid from the lungs as a diuretic


Calculated dosage
1.  Vetmedin    0.2 to 0.6 mg/kg/day (half dose in morning and the other half 12 hours later).
In this 19 kg dog, the dosage should be 3.8 mg to 11.4 mg/ divided in 50% 2 x /day 

2. Fortekor  0.25 - 0.5 mg/kg once daily with or without food.
In this 19 kg dog, the dosage should be 4.75mg - 9.5mg once a day.

3. Frusemide 1-4mg/kg orally to clear fluid from the body as a diuretic
In this 19 kg dog, the dosage should be 19 mg - 76 mg once a day.


Effective dosage in this 19kg dog after 2 months of trial and error:

Body weight 19 kg.
Vetmedin 5mg x 14 (1/2 twice a day)  ie. 5 mg divided into 50% of 2 doses 2x/day
Fortekor 20mg x7 (1/2 once a day) ie. 10 mg/once/day
Fursemide 40mg  x28 (1 twice a day). 40 mg 2x/day


CASE 2
There is another old coughing Chihuahua with congestive heart failure and abandoned by his owner who went to Thailand and now adopted by a young couple, doing well with the above-mentioned drugs for several months. Able to eat and no coughing. Once the drugs are not given, coughing recurs.  Some cases may need injections to stabilise. Coughing affects the caring owner as the nocturnal cough can be quite stressful for the dog and owner.

 

4. Red eyes in dogs

Email from Philipines Dec 8, 2014

	Dec 8 (3 days ago)
to judy

My dog's sclera has bloodshots and turns red  specially at night. In the morning its not that red. I dont know whats causing it. :(

REPLY FROM DR SING  DEC 8, 2014

Pl send two images of the red sclera and eye involved..

3 IMAGES SENT

Sorry I couldn't get a clear photo. Attached are photos of his right eye. It started on his red eye May (2014) this year. He's been on different eye drops since then but nothing really helped. Now his left eye are showing signs of bloodshots too. At first i thought it was glaucoma but it's not. Vets here are also clueless as to whats causing it.

EMAIL FROM DR SING  DEC 9, 2014

Any image of lower half of sclera?

Im having a hard time taking pics of the lower part of his sclera but right now its not red but it has blood shots as well. Thin ones.

Are you a Vet? Where are u from? I just came across an article online so i decided to email you. Im hope im not so much of a bother. Its just that im worried about my dog I dont want him to go blind. Ive already brought him to an animal hospital here in my country but they also dont know whats causing it.

Thank you..

EMAIL REPLY FROM DR SING DEC 10, 2014

Yes, I am a vet, Dr Sing Kong Yuen from www.toapayohvets.com

Which article you saw online? Which animal hospital and which country you are in?

Good morning doctor!

I think its your rticle about red sclera. I've been searching the internet of anything that could help me figure out whats causing the redness and bloodshots in my dog's right eye when i came across your article.

I brought my dog to vip hospital (vets in practice) already and recently in Animal House hospital here in the Philippines. But they can't figure out whats causing it. Accdg to them his eyes seem normal other than the redness and bloodshots of the sclera.

He's been on diff eye drops, ointments, steroids.. His eye improved but the sclera is still the same. His blood test results are all okay. His blood pressure is high so but even after giving him meds for hypertension his eye didnt improve.

If you have any idea as to whats causing i hope you can help me.. Thank youuu so much. :)

Your article is at:

http://www.bekindtopets.com/dogs/200912003Shingles_Dog_Attack_ToaPayohVets.htm

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REPRINT OF THE ARTICLE

This dog owner in her 50s with 2 children is one of those natural story tellers. She not only could tell stories very well but the way she acted and told it was a master performance.

"I was alone in the house when the 2nd attack occurred," she said when I asked about her two domestic workers. "I rolled up a carpet,  pick up XXX (the dog being attacked). Yet TTT held onto the left ear and chin of her sibling till gravity pulled TTT down to earth.

"Did TTT bite you?" I asked.

"No, she growled at me." the woman said. "That is why I boarded TTT
at your Surgery after the attack." TTT sounded like a ferocious Jack Russell and I took precautions of muzzling TTT for examination after the attack. Today was some 2 weeks later. The lady had now diagnosed shingles infection linked to the dog attack, according to her diagnosis. This is what she said to me.  

"Two days after the attack, I saw a circle of 'insect bites' on my right lower elbow area." She displayed her wounds on the inner side of her elbow joint. They were now maroon red with a black centre in the bigger wound. 

"Are you sure that the circular line of wounds were not caused by TTT biting you?"
This would be my first diagnosis although I am not a medical doctor.

"Well, TTT's teeth was sunk into XXX's left ear. I held XXX up till TTT had to let go as gravity pulled her downwards.  So, she could not have bitten me."
The lady waved her hand up and down to show that she had held XXX high up, until TTT gave up to the forces of gravity and dropped to the ground.    

"The next day, I felt tired," the lady continued. "Tingling sensations rippled from under the skin of my right elbow to my back shoulder", she pointed to her back. "More rashes appeared in the area. Watery blisters formed. The tingling sensation was unbearable. I quickly went to consult Dr Thiru, the famous skin specialist. Do you know him?"

"I don't know him nor have I met him," I said. "Is he the distinguished looking man with silvery grey hair and white sideburns?" I had attended a talk given by Attorney General Walter Woon's lecture "Criminal Aspects Of Medical Practice" to a full house of at least 1,000 doctors and lawyers in the Supreme Court Auditorium on Nov 30, 2009. The moderator was a doctor who is a skin specialist. "Yes," she confirmed my description of the good doctor.

"The doctor asked whether I had been to the vet?" the woman commented. "Probably my doctor was thinking that my right elbow I had been infected at your Veterinary Surgery."

I don't think the good doctor would have thought that she was infected by putting her elbow on the veterinary examination table and got infected by Shingles. I don't know why he asked whether she had visited the vet earlier.

"So, did he prescribe you the antiviral drug?" I was more interested on the cure. 

"He said to wait 3 days," the woman replied. "Then more rashes appeared. They become watery and burst. I felt tingling, as if some snakes were travelling up my hand to behind my back and forth. I quickly went to see him. He was not available but his colleague gave me the medication. Now I feel so much better and have the time to quickly get my 2 dogs vaccinated."

"My sister had shingles." I said. "The viruses travelled along her nerves in her leg and the serpentine lesion manifested as snake-like in appearance."

This woman did not have the serpentine tracks as she had sought prompt medical treatment. "If the virus completes the travel from one end of the nerve, go round the body, the person will die," the lady told me about a common Chinese belief. "That is why the Chinese temple medium used incense to burn the shingles skin. To kill off the head of the snake."

"Some Singapore people don't know what is the cause of this serpentine skin problem," I said. "So, they seek the help of Chinese mediums."

The lady enlightened me: "Actually, shingles is the re-activation of the chicken pox virus due to stress. The virus lurks in the body for a lifetime. It is extremely painful, itchy and causes tingling sensations." 

This lady is surely knowledgeable about shingles. I just could not believe that separating two dogs in a fight would lead to a shingle infection as this lady was definitely in good health.  I believe that there is a remote possibility that TTT had bitten her right elbow when the dog loosened her grip on XXX and was falling down to earth. I mean, how would the lady know since she was highly agitated and in that instant, TTT's bite would have resulted in what she first told me as "circular rashes" in a small area in the inner aspect of the skin of her right elbow. I remembered asking her to repeat what she said. She said "circular rashes".

She meant that she had rashes clustered in a circle. Or semi-circle. The pain and tingling sensations could be due to the spread of micro-organisms along the nerve and tissues originating from the bite wounds. This condition is documented in the skin to owners owners who had been scratched by the cat. 

These bite rashes from the upper and lower incisor teeth of the attacking dog would become infected. That could be the reason that the first doctor did not think this was a shingles infection. As for the appearances of more rashes in the surrounding area, it could be due to the scratching of the infected skin. This is my hypothesis which I am sure the lady would not agree.  I have not seen shingle infections in human beings. Maybe they manifest as rashes clustered in the circle too.     

Medicine is full of diagnostic mysteries. I asked to see the inner or medial aspect of the elbow again. I could see that the rashes covering an area of 10 X 10 cm of skin in the elbow. The biggest rash was 8 mm in diameter. It had a black centre. Other rashes were healing.

This is an incredible but true story of an apparent shingles infection linked to dog assault.  Did the attacking dog get any shingles as well?  She had really blood shot eyes. Red sclera in both eyes after her ferocious lunge for the jugular of the sibling who garnered more attention at home. The redness in both sleras persisted for several days. So, would this be caused by a virus activated by the high stress of trying to get rid of the rival in love? A latent herpes zoster-equivalent virus in the dog, a canine type of chicken pox virus that gets reawakened in times of high stress? This dog was lunging for the jugular of the sibling with only one intention. To kill a rival in who is favoured more by family members.  But her attempt was thwarted and now she was "in the doghouse". Or to be precise, waiting to be rehomed (Re-homing picture must be attractive).  

P.S.
1. Herpes zoster (Shingles). Anybody who has had chicken pox is at risk for developing shingles many years later. The chicken pox virus lies dormant in the person's body. Stress or a decreased immune system reawakens the virus, resulting in shingles infection. It appears as a rash. Rashes cluster around the eyes, face or body. The Shingles infection is also called herpes zoster. It is an extremely painful and itchy condition. Early aggressive treatment with antiviral drugs can lessen the length and severity of shingles attack.

2. Red scleras in the dog. I had encountered a few cases. Some are due to traumatic injuries. Some are a result of intense rubbing of the eye arising from some chemical spills. I note that there is a dog owner posting a picture of his dog with red sclera in a local website called Stomp.

I had 2 memorable cases of red scleras in Jack Russells.
2.1 This Jack Russell had a chew rope stuck inside its colon for some time.
2.2 This Jack Russell had intense abdominal pain and was vomiting. Exploratory laporatomy revealed petechial haemorrhages in the pancreas.
This present case would make it 3 memorable cases of Jack Russells with blood-shot eyes. E-mail to judy@toapayohvets.com if you have seen more cases. 

3. How your elderly dog can live longer?

PAYOH VETS toapayohvets.com       Date:   04 April, 2013   Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits. Health Screening For the Older Dogs Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written: 21 September, 2011 Date:  04 April, 2013 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Most dog owners in Singapore live hectic lives. There are just too many distractions and too much work or enjoyment. After an intense period of love and care for their new puppies, the senior dogs are just left alone as there is no time for them after their puppy hood. It is usually too late for many old dogs when they are sent to the veterinarian for some chronic disease problems. Veterinary costs become high as the dog is in poor health and need more intensive care.   Senior dogs are: Small and Medium-sized breeds: Over 7 years Large and Giant-sized breeds: Over 5 years. For those who may want their senior dogs to live longer, here are the following health screening recommendations by Toa Payoh Vets: 1. Veterinary examination every 6-12 months including examination for tumours and growths, ear infections, eye diseases and skin diseases. Skin diseases are the top 3 cases in Toa Payoh Vets. An educational video is at: Video: Microscopic exam of ringworm  2. Blood tests to check for blood disorders, diabetes, liver and kidney diseases. Special veterinary diets can be given to prevent further health deterioration when such health screening show disorders of the liver and kidneys, prolonging the dog's life. 3. Urine tests to check on bladder and kidney infections and presence of urinary stones. Urine tests for bladder stones 3-months or periodically after operation as advised by your vet, but many Singaporean owners don't bother and bladder stones recur 3 times.  Some owners euthanase their dogs when stones recur but others incur high veterinary costs to get them operated. Monitoring of the urine and X-rays as advised by your vet after bladder stone removal would have prevented much medical costs.  5863. Five surgeries for bladder stone problem in a Shih Tzu 4. X-rays for arthritic hip joints (can't stand up easily), spinal column, heart and lungs. X-rays for bladder stones 3-months or periodically after operation as advised by your vet. 5. Ultra-scans of the abdomen for abnormal growths of the internal organs. 6. An MRI scan of the brain for brain tumours. 7. Dental check up and scaling every year. Prevention of oral tumours and oro-nasal fistulas (carnaissal tooth abscesses) in the old dog can be done if the owner checks his or her dog's teeth at the vet yearly. 5957. Oro-nasal fistula: Follow up 6 years later 6. Heart check for murmurs and heart diseases. 7. Stool test for blood, parasites. 8. Blood tests for allergens affecting your dog. 9. A report and discussion about the delay in senility, obesity, behavioural problems, skin problems and any questions related to each individual dog. 10. Excision of small skin, mammary, circum-anal and other tumours.  Tumours detected early can be excised saving the dog's life and reducing veterinary costs. Delaying treatment results in tumours growing and multiplying as in the circum-anal tumour. Many Singapore dog owners delay removal of their senior dog's tumours till they grown big, become smelly and bleeding, messing up the apartment. In such cases, the anaesthetic risks are very high and the dog may die on the operating table. An example of the investigation tests and surgeries done for one older dog with heart disease and another with gum tumour is shown below Case 1: Heart disease confirmed in an old companion   Cardiac Tamponade in a Labrador Retriever - Pt 1 Cardiac Tamponade in a Labrador Retriever - Pt 2 Case 2:  Get tumours excised by your vet when they are smaller  Old dogs are very high anaesthetic risks as they are seldom in the best of health unlike younger ones. Everyone is happy when the old dog does not die on the operating table after surgery. But every vet will have cases of old dogs dying on the operating table as it is impossible to get good clinical outcomes when the vets undertake high-risk anaesthetics. This is one main reason why some vets discourage or reject old dog surgeries. "The old dog will pass away before the circum-anal tumours grow much bigger," one vet said to the owner. But the dog lived longer, splattering the apartment with blood from the bleeding tumour and requiring frequent cleaning up.   \ 5646 - 5648.  Mammary adenoma. A kind Buddhist teacher. No further news from the teacher as at April 4, 2013 When a dog dies on the operating table, it is just too emotional for everyone including the operating veterinary surgeon. Such  deaths may be bad-mouthed by the owner or the family members to friends and recorded on the internet forum. The bad news adversely affect a vet's reputation that takes so much time and effort to build. So it is understandable if a vet does not want to operate on high-risk cases. I do avoid such cases if possible as deaths on the operating table means a beloved family member that has been growing up with the family children who have become adults is lost forever.   The average life-span of a big breed dog is 12 years. Oldest small breeds in Singapore can live up to 20 years. However, many die before they are 10 years of age due to bad health and other preventable causes such as bacterial infection of the heart valves due to severe gum diseases (preventable by regular 2-yearly dental scaling and checks), pyometra (preventable by early detection or spaying), kidney diseases, diabetes and  tumours like breast, testicular (undescended testicle), gum and circum-anal tumours (much less occurrence in a male dog that has been neutered). Many diseases such as circum-anal and undescended testicular tumours rarely occur in male dogs that have been neutered. If you don't wish to neuter your dog, please check his backside monthly as small circum-anal tumours are easily removed and cost you less too.   Tumours like breast tumours are best removed when they are small.   Case study. Breast tumours have spread to two breast. If excision is not done, all 10 breasts will be cancerous. The surgery was done at Toa Payoh Vets in 2008 and the owners had not returned as at April 4, 2013. Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements.  Updates will be on this webpage: www.toapayohvets.com/surgery/20080807Senior_Dogs_Health_Checks_ToaPayohVets.htm   Advert for Veterinary Technicians  or Nurses For Toa Payoh Vets BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER.  More case studies, goto:  Cats  or  Dogs To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129

Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: April 04, 2013 Toa Payoh Vets

How to take good care of your red-eared slider terrapin

TERRAPINS

1. Don't overfeed. Too much protein or phosphorus. Variety of food.
2. Don't underfeed. Picky terrapins. Variety including meal worms, fish, vegetables, shrimps from pet shops.
3. Don't use gravel. Rough causing shell injuries. Eaten causing intestinal impaction.
    Smooth pebbles.
4. Inadequate basking area. Need to dry completely. A 2-in-one UVB and heating lamp will be best. Basking area 85-92 deg F. Cannot thermo-regulate. So need warmth. Prevent shell rot or algae. Shell health important. No obstruction to UVB light to terrapins by objects.
5. Don't pull off shedding scutes as new shell is growing. May cause shell rot. Let shedding come off unless too long to fall off. Consult vet.
6.  Water quality. Chlorine causes resp. problems. Healthy terrapins eat and poop a lot. Good canister filtration. Change water weekly. Plants to break down ammonia and nitrates.
7. Escaping turtles. Like to climb out of tank over objects. Prevent cat and dog visit or trauma.
8. Salmonella from terrapins (carriers of Salmonella in poo, no signs) to people. Wash hands.
9. Don't release captives in the wild.






http://2010vets.blogspot.sg/2013/03/1331-images-used-for-caring-for-your.html


http://2010vets.blogspot.sg/2013/02/1279-swollen-eyes-in-two-terrapins.html


http://2010vets.blogspot.sg/2014/09/1499-4-year-old-terrapin-has-swollen.html


Metaplasia of the terrapin's eyes
http://2010vets.blogspot.sg/2013/01/1267-metaplasia-of-terrapins-eyes.html


Ear abscess in a terrapin
http://2010vets.blogspot.sg/2014/01/the-lady-who-googled-ear-abscess.html


Turtles webpage of Toa Payoh Vets
http://www.asiahomes.com/singaporepets/20130131turtles_ToaPayohVets.htm



A moaning terrapin
http://www.sinpets.com/F5/20120919red_eared_slider_moans_toapayohvets.htm


Cheek ulcer in a terrapin, Gasping.
https://www.youtube.com/watch?v=OyfgbGNAFVQ&feature=youtu.be

1. How to minImise anaesthetic death in an old dog

1. How to minmise anaesthetic death in an old dog

Informed consent

History and physical examination
Blood test, ECG and X-rays
Sedation dosage 50% for dogs over 5 years old or not as healthy
Antidote to sedation
Emergency drugs
IV drip, antibiotics and diuretic
Intubation
Duration of anaesthesia
Close monitoring of anaesthesia by experienced assistant
Duration of surgery
Antidote
Recovery. Not to go home immediately
Post op antibiotics and painkillers for extracted teeth


Oct 28, 2014.  A father and young adult daughter presented this gentle 7-year-old male Sheltie for dental scaling. A friend's Maltese had died after dental scaling by another vet and so the owners were worried about anaesthetic death. "Dogs usually do not die under anaesthesia or after anaesthesia," I said to the father. "Unless the dog has heart disease or poor health."

A thorough physical examination showed that this Sheltie with bad breath was generally healthy in heart and lungs. The heart beats were irregular. 50% sedation  of domitor and ketamine IV calmed this nervous Sheltie.

Health screening including a complete cell count and X-rays of the chest is advised. No ECG is done.

In this case, I gave an IV drip, with IV baytril, frusemide and Vit B complex.  

It is very important to provide a very close monitoring of the maintenance of isoflurane gas at 0-2%, oxygen flow rate at 2 litres/minute to ensure that minimal anaesthesia is being given. The dog did wake up in the midst of dental scaling as the maintenance dose was 0.5%.

He was intubated again and maintained at 2%. The dog woke up fast and went home 3 hours later.  Follow up 2 days later showed that the dog is OK. The dog had been given dry dog food and milk since young. He likes only certain brands of milk. Well beloved family dog and in excellent body condition.


FOLLOW UP
Oct 28, 2014


A new client - father and young adult daughter brought in a 7-year-old male entire Shetland for dental scaling.  Their friend's Maltese had died after dental scaling in another vet practice and so they did not want to go to the practice.

"Very rarely do dogs die after waking up from anaesthesia given for dental scaling," I said. "Was the Maltese having heart diseases?"  The owners of the gentle full sized Sheltie did not know but they would avoid this friend's vet

No vet can guarantee no anaesthetic risk. Even people do die.

PHYSICAL EXAMINATION
Other than periodontal disease grade 4 (tissue attachment loss over 50%), I noted that this Sheltie had congested maroon red gums, not the normal pink ones. You can see this in the video. Why? The capillary refill time was longer than the usual 2 seconds. Blood test showed that this dog had a higher than normal amount of haemoglobin in his blood at 19.1 (12-18).  The total red cell count was normal. The haematocrit was normal too.  Platelets were normal. What does it mean? Was he fed some supplements?


BLOOD TEST on 27.10.14  Abnormal values

Urea 12.3  (4.2 - 6.3)
Creatiine 65  (89-177)
Haemoglobin 19.1 (12-18)

All the other blood values within normal limits.


FOLLOW UP - Day 2 after dental scaling
The dog was a bit tired yesterday but is Ok and eating today.

"Tartar started to build up fast in last 3 years," the father said that the dog was not given meat. "Could it be the milk making the kibbles soft?". This dog had the biggest crusty tartar I had ever seen in a dog (see image/video).

The dry dog food was  Science Diet Lamb and Rice with a brand of dog's milk since young. Dog treats were given.


ADVICES 2 DAYS LATER
No milk and treats to prevent tartar build up.
Eat dry food without milk and drink water.
Blood test 4 weeks later to check on the urea levels.

This case shows that a blood test is important for screening the health of an older dog. The owner was given the option. The blood test was done by me as this dog had an unusual congested gums.




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DENTAL WORK WITHOUT ANAESTHESIA IN A VERY OLD POMERANIAN WITH HEART DISEASES Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Written: 04 September, 2010

toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129

Can an old vet (>50 years old) change his mindset of not using general anaesthesia and sedation for very old dogs so that she has a high probability of being alive at the end of dental work? The only chances of her dying would be from fright (heart failure) due to the stress of the dental work without general anaesthesia. Seldom are such old dogs healthy. They usually have heart disease and general anaesthesia kills them as they are also very old. Is it possible to perform dental extraction with no general anaesthesia for such very old dogs with heart diseases and a mouthful of decayed and rotten teeth as shown in the pictures of a case of a 16-year-old Pomeranian below?  16-year-old. Home cooked food. Teeth encrusted with tartar but surprisingly there was no strong bad breath smell. An I/V glucose drip is important for aged dogs during operation. Emergency Lasix was given I/V when the dog coughed trying to clear her throat. Dog goes home with no teeth left.  Vet Intern Ms Toh arranged the teeth neatly for photography. "How many teeth has an adult dog?" I tested Ms Toh who had great interest to study veterinary medicine. She shook her head. The answer is 42.  If she survived, her quality of life (no daily oral pain and infection and hence able to enjoy her food and put on weight). She would be more active and alert. She might live to a ripe old age the bacteria in her mouth had been rid of. Bacteria constantly produce toxins and lower her immune system.  In the above case, the Pomeranian was in good condition for her age. She looked like an 8-year-old dog rather than an ancient canine. She had no fever and no abnormal respiratory rate. The pulse pressure was lower. The dog was on heart medication prescribed by Vet 1 for some years.  However, she was underweight. Her mouth was not smelly despite the presence of large amounts of tartar. The owner requested "manual scaling" as she had discovered in the internet forum that I was highly recommended as I do "manual scaling" (without general anaesthesia). "I don't do manual scaling," I told her that there was a mistake in the internet forum she had researched. "How many manual scaling in dogs have you performed?" she asked. "None," I said. Ultrasonic dental scaling is the method I use. However, this old dog needed dental extraction and not dental scaling. The roots of the teeth were all loose and infected. "Manual scaling" (without general anaesthesia) would not be in the interest of this dog as the bacteria still would be multiplying under the roots below the gums. Dental scaling  would be what the lady wanted but this was not the right thing to do for the dog.  "There is a risk that your old dog may die from fright due to the pain of tooth extraction without general anaesthesia," I informed the lady. She was surprised and said, "Let me have some time to think as to what to do." I expected the lady to go home on this sunny Sunday afternoon of May 3, 2009. I had my hands full on this busy Sunday. However, she returned and decided to take the risk. THE PROCEDURE An I/V glucose drip was given to help to increase the blood pressure as the pulse was weak. Into the drip set, I gave Baytril antibiotic to reach the dog immediately to kill the bacteria. The dog was quite docile and so there was not much worry.  Two front incisor teeth were extracted. The dog started coughing as if to clear phlegm in her throat.  This indicated that the oral heart medication given to the dog was not effective to remove the fluid in the lungs (pulmonary edema).  What now? Cease operation? Going back to the basic of veterinary pharmacology, I needed a drug to clear the water from the lungs quickly. I broke a vial of Lasix and injected it into the IV  drip. The drug would take away fluid from clogging the airways by taking it into the blood-stream. I waited 5 minutes   before continuing dental extraction. One or two teeth were extracted at 1-2-minute intervals. The teeth were so loose that most of them could just be pulled out easily. There was little bleeding. Tissues were used to control the bleeding. When the bleeding had stopped, the other teeth were extracted. The dog had not even coughed throughout the process of dental extraction. He was apprehensive.  Suddenly the dog shifted and the IV catheter came out. Intern Ms Toh had informed me that there was a skin swelling above the catheter. 3 Elastoplasts strips and a wrap-around bandaged had been used to fix the catheter in place but we had anticipated that this would happen. The dog had around 100 ml of glucose and that would be sufficient. Since the catheter had popped out of the vein, the rest of the fluid was given subcutaneously. Caution would be the key and there was rest in between each dental extraction, dragging the process to over one hour. Prevention of heart failure due to fright was paramount. After all, the owner wanted an effective veterinarian who would produce a live dog at the end of the day, not an efficient one with a dead body.     CONCLUSION The dog had 23 loose and rotten teeth extracted with little pain and little bleeding. The lady's eyes brightened when she returned later and was told that her dog was OK.  The dog was alert and her excellent coat shone golden in the evening rays of the evening sun as I took her photograph. As the dog was not vaccinated, I did not want the dog to be hanging around the Surgery. The lady put the dog in her car while she paid the bill. Well, the dog peed inside her car, but she was not upset. Her best friend was alive and that was what mattered to her.   This is the sole case of me doing dental work without general anaesthesia in my 2 decades of small animal practice. I record this in detail to share my unusual experiences with other veterinarians. If the dog had kicked the bucket, the owner would be very unhappy as she had 14 years of companionship with this old friend after adoption from the SPCA as a 2-year-old. It was fortunate that the old Pomeranian did not die of fright on the operating table.  I don't want to do any more such cases as this will tempt the God Of Death. This was not a simple case as the dog was coughing. If the coughing continued, the dog was be stressed out and die of heart failure. Therefore, the vet must know what to do when things don't proceed smoothly. Of course, the best way is not to accept such a high-risk case as deaths of companion animals on the operating table are never forgiven or forgotten by the owner and her family.       NOTE: It would be wise for dog owners to get the dog's teeth check every year and get dental scaling done when the dog is young and fit. Continue with tooth brushing after dental scaling. UPDATE IN SEP 4, 2010 FROM OWNER:The dog lived to a ripe old age and passed away in April 2010. The post-operation feedback from the owner indicated that the dog had oral pain and low blood sugar.          E-mail to Dr Sing dated Sep 2, 2010 bekindtopets.com/dogs/20080828Dog_Dental_Problems _Singapore_ToaPayohVets.htm Dear Judy,  I saw the case study on the above website.  I am the owner of this dog. Her name is She. She passed away this year 11 April. It was a Sunday morning.  Please send my regards to Dr Sing.  On the case study, I would also like to update you what happened after I got home.   The surgery was a success as my dog was indeed alive and well. Just like any other beings, they need rest after surgery. However dogs will always attempt to walk or run as its part of their nature, not knowing itÂ’s exhausting. One the first night after the surgery, my dog collapsed suddenly and started to whine. I picked her up and gave her a massage, which she was able to stand on her feet soon after. This happened for another 2 times in a day.  I realized it may be trauma and shock, and maybe low glucose level. She is also not eating well. Where is she going to get the “energy”? She was already on long term medication for heart, plus after surgery medicine. I was not prepared for more medication for my little 16+ yr old.  I brought her to TCM. I think this doctor is the only doctor in SG who provides acupuncture for dogs. He is (Name given). I asked this doctor to also do treatment for her appetite, her heart, and other senses such as hearing and sight. She responded very well after the first treatment. She was also beginning to eat! And best part is she and I had eye contact, it shows that sheÂ’s getting more alert.   She continued the treatment for about 1 month, about 5 consultations. She recovered very well. Soon after she starts to bite all people who attempt to touch her, including myself. I think itÂ’s the surgery trauma and old age crankiness. But I also think that if she bites it means she is alert to her surroundings. I see it as something positive, sometimes, funny. Because, no teeth still want to bite people? No more bad breathe and no more toothache. I was not worried about bacteria possibly worsening her heart condition anymore. Without teeth, her tongue always sticks out! Amazingly she looked even younger and cuter!   I wrote this to you because as fate has it, Dr Sing has indeed changed the quality of her life.   But he is also right, itÂ’s very risky. What if the owner did not take precaution AFTER the surgery?  I have attached 4 pictures. 1 taken in May 2009, 1 in Sep 2009 and 1 less than a month before she left in 2010.  She was very lucky, to have met the right people.  Thank you.   Best Regards,   E-mail from Dr Sing dated Sep 4, 2010 I am Dr Sing and got your good news of your dog living to a ripe old age.  Thank you for your email and important feedback post-operation as I seldom get any feedback. Most likely it was low blood sugar as you diagnosed. It could be the post-dental extraction pain.  Your pictures are great. Pl give permission to post the pictures.  I hope all are well with you.   E-mail to Dr Sing dated Sep 4, 2010 Hi Dr Sing, Great to hear from you!  Sorry I would like to rephrase, I meant her fear and anxiety on the surgery table would definitely caused that “weakness” which makes her faintish. Yes, I should write as low blood sugar. ItÂ’s a normal after-surgery process. I remember feeding her sugar/glucose water.  I am well, thank you. I guess this is one thing all dog owners have to go thru.  Until yesterday, I could never have imagined how hard you guys work over the metal table, while I was stoning in your clinic. It was a very detailed re-enactment. Thank you for sharing. It was heartwarming for me.  I hope my feedback could help you and your furry patients. Please feel free to use the pictures, itÂ’s my pleasure. Best Regards TIPS FOR VETS: POST-OPERATION PAINKILLERS I did not give the dog pre-op NSAID pain-killer nor after the dental extraction as I would do for a younger dog. This is because this dog's kidneys would not be as good as a younger dog to withstand any adverse reactions on the kidneys from NSAID drugs. NSAID drugs are not to be given to dogs with kidney disorders and though no blood tests to ascertain renal function were taken, I expected the kidneys and livers of a 16-year-old dog not to be as normal as to metabolise NSAID drugs without dying of side effects and thereby distressing the lady owner. As for post-operation sugar paste, this would be given for old dogs. In very old dogs, it is very risky to use injectable anaesthesia. In this case, isoflurane gas would be safer but it was not used as the owner