Dentistry , Practical Dentistry

Disorders of Dental Hard Tissues in Dogs

  •  
  •  
  •  
  •  
  •  
  •  
  •  

pdf_button


Brook A. Niemiec, DVM, FAVD, Diplomate AVDC, Southern California Veterinary Dental Specialties, San Diego, California

Many types of hard tissue pathology affect small animal veterinary patients. Many of these are caused by a form of trauma, but acidic degradation, infection, and genetics also play a role.

ENAMEL HYPOCALCIFICATION/HYPOPLASIA1-4

Enamel is a very thin (< 1 mm) material on the surface of the tooth crown. Ameloblast cells initiate enamel formation, and are only present during this process.5,6 Enamel is created prior to tooth eruption and cannot be naturally repaired after teeth erupt.

PERTINENT TOOTH ANATOMY6,12

ENAMEL

The tooth crown is protected by a thin shell of enamel. Enamel thickness in cats and dogs varies from approximately 0.1 mm to 1 mm.16

PULP

Tooth pulp is a soft tissue that contains blood vessels, nerves (sensory only), and other types of cells, including odontoblasts, fibroblasts, and fibrocytes. Blood enters the tooth through the apical delta, along with the nerve bundles.

Screen Shot 2015-06-18 at 11.22.40 AM

Figure. Medical illustration of a maxillary canine in a dog

DENTIN

Dentin is arranged in tubules—these extend from the pulp to either the area where dentin and enamel meet (dentinoenamel junction) or the root where cementum and enamel meet (cementoenamel junction).

Dentinal tubules are filled with fluid and odontoblastic tendrils, which are cytoplasmic extensions of odontoblasts. These tubules are major pathways for diffusion of material across dentin—a concept known as dentin permeability.1

DENTIN–PULP COMPLEX

Due to the interdependent relationship between pulp and dentin, these two tissues are best considered as one entity: the dentin–pulp complex. Pulp and dentin function as one unit because odontoblasts, which line the pulp cavity wall, project their extensions into dentin. Also, odontoblasts are responsible for formation of dentin. In turn, pulp tissue is dependent on dentin for protection.

Causes & Development

Hypoplasia/hypocalcification results from disruption of normal enamel development.7,8

  • Enamel hypocalcification occurs when normal amounts of enamel are produced, but are hypomineralized, making the enamel softer than normal.
  • Enamel hypoplasia occurs when the enamel produced is hard, but thin and deficient in amount.

Enamel hypocalcification can result from trauma to an unerupted tooth, which can affect one or several adjacent teeth, and is the most common acquired cause. While this defect may originate from external trauma, it is often associated with extraction of deciduous teeth.

Enamel hypoplasia may result from a hereditary condition known as amelogenesis imperfecta,9 which results when a decreased amount of enamel matrix is applied to teeth during development. In these cases, nearly all teeth, and all surfaces, are involved.

A severe systemic infectious (for example, canine distemper virus infection that occurs in puppies before the teeth have erupted) or nutritional condition may also result in improper enamel production.9

Clinical Signs & Diagnosis

Common signs of enamel hypocalcification/hypoplasia are listed in Table 1. These signs emphasize that prompt therapy is critical to the health of the patient.

Screen Shot 2015-06-18 at 11.22.51 AM

Prior to therapy, dental radiographs must be exposed to evaluate whether tooth nonvitality or root malformation (Figure 1) is present.

Treatment Options

Treatment goals include:

  • Removing sensitivit
  • Avoiding endodontic infection by occluding the dentinal tubules
  • Smoothing the tooth to decrease plaque accumulation.

Screen Shot 2015-06-18 at 11.23.14 AM

Composite restoration is the most effective way to accomplish these goals (Figure 3), and it also improves tooth appearance. However, this therapy only provides a small amount of strength.

Crown therapy can be performed if damage is severe and the client is interested in a permanent correction (Figure 4).1

Smoothing and bonded sealant application can be considered for minor areas of disease or nonstrategic teeth, and in patients whose owners have financial concerns (Figure 5). For more information on this procedure, see Bonded Sealant Application for Crown Fractures (July/August 2011), available at tvpjournal.com.

Extraction may be performed, but it is generally not recommended.

CARIES1,2,9

Caries (in humans, commonly called “cavities”) occur when acid dissolves the hard structures of the teeth. Reports on prevalence vary widely, which may be due to overdiagnosis of discolored surfaces,18 but caries are fairly rare in dogs and almost unheard of in cats. A study that evaluated dogs seen at a veterinary dental referral facility found a prevalence of 5.3%.19

Causes & Development

Caries lesions begin in areas where food becomes trapped (Table 2); bacterial digestion of the food produces acid, which initiates the lesion.20 Therefore, home care can help avoid these lesions.

Development of caries can ultimately affect the endodontic system.

  1. The initial lesion—a surface decalcification of the enamel—is caused by a drop in pH .
  2. Demineralization follows the direction of the enamel rods.
  3. Eventually, caries breaks through the enamel and invades the dentin. Once this occurs, the lesion expands laterally fairly quickly, as dentin is less mineralized than enamel.
  4. Once dentin is destroyed, the unsupported enamel will collapse, expanding the lesion.
  5. These lesions can progress into the endodontic system, resulting in pain and infection.

Clinical Signs & Diagnosis

Outwardly, caries appear as a discolored tooth defect (Figure 6). Discoloration is usually brown to black, but can be white very early in development. Early lesions can mimic wear, and are best diagnosed by tactile feel of the defect with a sharp explorer (Figure 7). Healthy tooth structure is solid, whereas caries is soft and sticky. When penetrating the caries, the explorer will experience “tug back.”

Prior to therapy, dental radiographs must be exposed to determine the size of the defect and evaluate tooth vitality. Caries appear as radiolucent areas (Figure 8).

Treatment Options

Evidence of endodontic disease:

  • Root canal therapy is required prior to restoration.
  • Crowns are recommended since damage is likely significant—creating teeth susceptible to fractures.
  • Extraction can also be considered.

Early to moderately advanced caries:

  • Removal of all diseased tooth structures is required prior to restoration.
  • Composite resin restoration is generally the best choice (Figure 9).
  • Amalgam, however, is also a valid option.

Lesions at or below the gingival margin:

  • Glass ionomer restoration is most likely the best treatment.21

Screen Shot 2015-06-18 at 11.23.27 AM

Screen Shot 2015-06-18 at 11.23.33 AM

DISCOLORED (INTRINSICALLY STAINED) TEETH

Intrinsically stained teeth are discolored teeth in which the abnormal color stems from inside the tooth, specifically the dentin–pulp complex.

Causes & Development1,2

In dogs, intrinsic staining most often results from blunt trauma of sufficient force to cause pulp hemorrhage, but not enough to fracture the tooth. However, in other dogs, there may be no history of trauma and discoloration occurred for other reasons. For example, another possible, but unlikely cause, is tetracycline use in very young patients; most, if not all teeth, become discolored (yellow/brown).

Intrinsic staining results when extravasated blood is forced into the dentinal tubules and then degenerates:

  1. A tooth stained by degenerating blood products following pulp hemorrhage appears pink immediately after the injury, eventually becoming darker brown or gray (Figure 10).
  2. Although dental pulp can heal after injury, the vast majority of discolored teeth are nonvital.
  3. Once the tooth becomes nonvital, it often becomes infected via the blood supply, in a process known as anachoresis.
  4. Once the tooth becomes infected, it acts as a bacterial fortress, allowing bacteria to create periapical infection, which may spread to the entire body.
  5. Intrinsically stained teeth can also cause clinical abscessation.

Screen Shot 2015-06-18 at 11.23.40 AM

The only exceptions to the above process are:

  • Young patients: The large endodontic system and good blood supply of these patients allow them to recover from the inflammatory pulpitis, and the tooth returns to normal color in a few weeks. If this does not occur, the tooth should be considered nonvital.
  • Patients with only discolored cusps (rest of the tooth unaffected) (Figure 11): These teeth should be radiographed and transilluminated; if both results are normal, the tooth should be monitored.

Screen Shot 2015-06-18 at 11.23.49 AM

Clinical Signs & Diagnosis

Clinical observation is generally diagnostic.

Transillumination should be performed if there is any question whether the tooth is discolored (Figure 12). Note: As pulp cavity diameter decreases with age, transillumination becomes less reliable and eventually impossible.

Dental radiographs should also be exposed to determine the condition of the roots.

  • Nonvitality is indicated by change in width of the endodontic space or periapical lucency (Figure 13).
  • Pulp necrosis is indicated by a larger root canal diameter than the contralateral tooth.
  • Generalized pulpitis is indicated by a smaller diameter root canal space than the contralateral tooth.
  • Periapical lucency is evidence of endodontic infection, causing bony resorption.

Normal radiographs do not indicate that the tooth is alive and not infected, but some will argue that lack of radiographic changes indicates the tooth has responded to the insult and is vital. However, radiographs are not very specific for diagnosing infected teeth22 because:

  • 30% to 50% of the bone must be lost before it is appreciated radiographically23
  • The endodontic system changes very gradually in older pets.5

A 2001 study by Hale demonstrated that only 40% of intrinsically stained teeth had radiographic signs of endodontic disease.24 However, when physically examined, 92.7% were nonvital and infected. In our experience (over 1000 cases), all discolored teeth have been nonvital and infected.

Treatment Options1,2

Discolored teeth (with the exceptions noted earlier) are generally irreversibly inflamed or necrotic. Once the endodontic system becomes nonvital and/or infected, the tooth must be removed. There are 2 main options for removal.

Root canal therapy is the treatment of choice for larger teeth, such as canines and carnassial teeth (Figure 14).

Extraction is a viable alternative for small teeth, such as incisors and premolars; however, root canal therapy is also indicated if the client wishes to save the tooth.

Screen Shot 2015-06-18 at 11.23.57 AM

ABRASION/ATTRITION1

These lesions are similar to uncomplicated crown fractures; however, they result from long-term wearing of the tooth as opposed to a 1-time traumatic event.

Both of these lesions are created by chronic contact with a hard object.

  • Abrasion is caused by a tooth wearing against something foreign.
  • Attrition is caused by tooth-on-tooth contact.

Attrition is caused by a malocclusion in which the opposing teeth are in contact, which may be due to:

  • A level bite—a mild class III malocclusion (undershot) and most common cause (Figure 15)25
  • Maxillary third incisors creating attrition on the mandibular canines (Figure 16)
  • Improper reduction of a maxillofacial fracture.

Abrasion can be caused by many different objects but, in general, is due to very aggressive chewing, which is more common in large breed dogs.

  • Chronic chewing on toys, such as tennis balls, wears down the canines and premolars (Figure 17).
  • Chronic chewing on the skin due to allergic dermatologic disease typically wears down the canines and incisors, often to the gum line (Figure 18).
  • Chewing on a chain link fence damages the distal aspect of the canines (Figure 19).

Screen Shot 2015-06-18 at 11.24.03 AM

Screen Shot 2015-06-18 at 11.24.09 AM

Treatment Options

All teeth with attrition or abrasion should be radiographed to ensure tooth vitality. If there are signs of endodontic disease (clinical or radiographic), required treatment is root canal therapy or extraction.

Treatment of dental attrition is generally not necessary—unless there is evidence of endodontic disease (clinical or radiographic)—because slowly exposed dentin generally becomes sclerotic and subsequently impervious to pain and bacterial invasion.

Screen Shot 2015-06-18 at 11.24.17 AM

  • Slight odontoplasty with a fine diamond or white stone bur should be performed to alleviate any contact, followed by application of a bonded sealant.
  • Extraction or odontoplasty with restorative or endodontic treatment should be performed before restoration of deep defects, such as those on the mandibular canines caused by maxillary third incisors, because the malocclusion has reached equilibrium—any restorative creates new contact and discomfort.

Treatment of dental abrasion, such as restorative therapy, is not generally indicated because slow progression of abrasion typically results in sclerotic dentin.

Behavior modification is the most important form of therapy, and may include:

  • Supervising play time
  • Changing toys to less abrasive ones
  • Modifying the cage
  • Treating allergic dermatitis.

Cast metal crowns can help “build up” canine teeth if behavior modification is not possible and the client wishes to protect the tooth and provide more tooth surface (Figure 20).

Full-coverage cast metal crowns are strongly recommended to strengthen teeth in dogs that have significant damage on the distal aspect due to fence chewing, as they are in great danger of fracturing if not protected (Figure 21).1 I have had excellent long-term success with this technique in military and police dogs. However, some veterinarians favor a three-quarter crown to decrease the amount of tooth structure removed.26

IN SUMMARY

Any time dentin is exposed, tooth sensitivity and inflammation results. In addition, teeth with direct pulp exposure are initially exceedingly painful, and then invariably become infected. These teeth can and should be restored.

Common options for restoration include bonded sealants, composite restoration, and crowns. Most of these techniques are easy to learn, taught at certain training centers, and inexpensive to initiate in practice. When the pulp is involved (including discoloration), treatment is directed at removing the infected root canal system, which can be accomplished by root canal therapy or extraction.

Client education is the key to gaining acceptance of treatment recommendations. The article Dental Services: Good Medicine for Patients & Practices (September/October 2011), available at tvpjournal.com, discusses the client education process with regard to dentistry.

FIGURE CREDITS

Figure 1: Reprinted with permission from Small Animal Dental, Oral, and Maxillofacial Disease—A Colour Handbook. Niemiec BA (ed). London: Manson, 2010.
Figures 2 to 7, 20, and 22: Reprinted with permission from Restorative Dentistry for the General Practitioner. Niemiec BA. Tustin, CA: Practical Veterinary Publishing, 2013.
Figures 12 and 13: Courtesy Dr. Jerzy Gawor.
Figures 14 and 15: Reprinted with permission from Veterinary Dental Applications in Emergency Medicine & Critical or Compromised Patients. Niemiec BA (ed). Tustin, CA: Practical Veterinary Publishing, 2012.
Figures 16 to 18: Provided by Rob Yelland and reprinted with permission from Veterinary Orthodontics. Niemiec BA (ed). Tustin, CA: Practical Veterinary Publishing, 2012.

References

  1. Dupont G. Pathologies of the dental hard tissues. In Niemiec BA (ed): Small Animal Dental, Oral and Maxillofacial Disease—A Colour Handbook. London: Manson, 2010, pp 128-159.
  2. Niemiec BA. Oral pathology. Top Companion Anim Med 2008; 23(2):59-71.
  3. Niemiec BA. Pathology in the pediatric patient. In Niemiec BA (ed): Small Animal Dental, Oral and Maxillofacial Disease—A Colour Handbook. London: Manson, 2010, pp 128-159.
  4. DuPont GA. Restorative dentistry. In Slatter D (ed): Textbook of Small Animal Surgery, 3rd ed. Philadelphia: Saunders, 2003, pp 2678-2686.
  5. Lewis JR, Reiter AM. Anatomy and physiology. In Niemiec BA (ed): Small Animal Dental, Oral and Maxillofacial Disease—A Colour Handbook. London: Manson, 2010, pp 9-38.
  6. Theuns P. Endodontic anatomy. In Niemiec BA (ed): Veterinary Endodontics. Tustin, CA: Practical Veterinary Publishing, 2011, pp 5-15.
  7. Neville BW, Damm DD, Allen CM, Bouquot JE. Abnormalities of teeth. Oral and Maxillofacial Pathology, 2nd ed. Philadelphia: WB Saunders, 2002, pp 49-106.
  8. Greenfield BA. Enamel defect restoration of the left mandibular first molar tooth. J Vet Dent 2012; 29(1):36-43.
  9. Wiggs RB, Lobprise HB. Clinical oral pathology. In Wiggs RB, Lobprise HB (eds): Veterinary Dentistry Principles and Practice. Philadelphia: Lipincott, 1997, pp 351-434.
  10. Wiggs RB, Lobprise HB. Oral anatomy and physiology. In Wiggs RB, Lobprise HB (eds): Veterinary Dentistry Principles and Practice. Philadelphia: Lippincott, 1997, pp 62-65.
  11. Trowbridge HO, Syngcuk K, Hideaki S. Structure and functions of the dentin-pulp complex. In Cohen S, Burns RC (eds): Pathways of the Pulp, 8th ed. St Louis: Mosby, 2002, pp 411-456.
  12. Startup S. Tooth defense and response. In Niemiec BA (ed): Veterinary Endodontics. Tustin, CA: Practical Veterinary Publishing, 2011, pp 16-36.
  13. Debowes LJ. Problems with the gingiva. In Niemiec BA (ed): Small Animal Dental, Oral and Maxillofacial Disease—A Colour Handbook. London: Manson, 2010, pp 159-181.
  14. Perry DA, Schnid MO, Takei HH. Phase I periodontal therapy. Carranza’s Clinical Periodontology. St. Louis: WB Saunders, 2006, pp 722-727.
  15. Niemiec BA. Pathogenisis and etiology of periodontal disease. In Niemiec BA (ed): Veterinary Periodontology. Ames, IA: John Wiley & Sons, 2013, pp 18-34.
  16. Crossley DA. Tooth enamel thickness in the mature dentition of domestic dogs and cats—preliminary study. J Vet Dent 1995; 12(3):111-113.
  17. Luukko K, Kettunen P, Fristad I, Berggreen E. Structure and function of the dentin-pulp complex. In Hargreaves KM, Cohen S (eds): Pathways of the Pulp. St Louis: Mosby, 2011, pp 452-495.
  18. Verstraete FJM. Oral pathology. In Slatter D (ed): Textbook of Small Animal Surgery, 3rd ed. Philadelphia: WB Saunders, 2003, pp 2638–2651.
  19. Hale F. Dental caries in the dog. J Vet Dent 1998; 15(2):79-85.
  20. Zero DT. Dental caries process. Dent Clin N Am Cariology 1999; 43(4):635–661.
  21. Chiaya S. Anusavice KJ (ed): Phillips’ Science of Dental Materials, 11th ed. St. Louis: Saunders, 2003, pp 443-494.
  22. Patel S, Wilson R, Dawood A, et al. The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography—Part 2: A 1-year post-treatment follow-up. Int Endod J 2012; 45(8):711-723.
  23. Mulligan TW, Aller MS, Williams CA. Periodontal disease. Atlas of Canine and Feline Dental Radiology. Trenton, NJ: Veterinary Learning Systems, 1998.
  24. Hale FA. Localized intrinsic staining of teeth due to pulpitis and pulp necrosis in dogs. J Vet Dent 2001; 18(1):14-20.
  25. Yelland R. Class III malocclusions. In Niemiec BA (ed): Veterinary Orthodontics. Tustin, CA: Practical Veterinary Publishing, 2012, pp 110-115.
  26. Luskin IR. Three-quarter crown preparation. J Vet Dent 2001; 18(2):102-105.

Author_BA NiemiecBrook A. Niemiec, DVM, FAVD, Diplomate AVDC, is chief of staff of Southern California Veterinary Dental Specialties, with offices in San Diego and Murrieta, California, and Las Vegas, Nevada.

DMCA.com Protection Status
[gravityform id="6" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper' id='gform_wrapper_6' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_6' action='/disorders-of-dental-hard-tissues-in-dogs/'> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_1' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_3' >First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_6' >Last</label> </span> </div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_7' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_7' >Profession / Role<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Veterinarian' >Veterinarian</option><option value='Veterinary Nurse / Technician' >Veterinary Nurse / Technician</option><option value='Practice Manager / Veterinary Assistant / Support Staff' >Practice Manager / Veterinary Assistant / Support Staff</option><option value='Student (Veterinarian or Veterinary Nurse)' >Student (Veterinarian or Veterinary Nurse)</option><option value='Other' >Other</option></select></div></li><li id='field_6_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_15' class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' >Inbox Preferences</label><div class='gfield_description' id='gfield_description_6_15'>Customize your inbox by selecting the areas you are most interested in. </div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='NAVC Better Care Weekly&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.&lt;/div&gt;' checked='checked' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>NAVC Better Care Weekly<br><div style="font-size: 12px; color: #808080;">A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.</div></label> </li><li class='gchoice_6_15_2'> <input name='input_15.2' type='checkbox' value='Today&#039;s Veterinary Business eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.&lt;/div&gt;' id='choice_6_15_2' /> <label for='choice_6_15_2' id='label_6_15_2'>Today's Veterinary Business eNewsletter<br><div style="font-size: 12px; color: #808080;">Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.</div></label> </li><li class='gchoice_6_15_3'> <input name='input_15.3' type='checkbox' value='Today&#039;s Veterinary Nurse eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.&lt;/div&gt;' id='choice_6_15_3' /> <label for='choice_6_15_3' id='label_6_15_3'>Today's Veterinary Nurse eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.</div></label> </li><li class='gchoice_6_15_4'> <input name='input_15.4' type='checkbox' value='Today&#039;s Veterinary Practice eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div><script type='text/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 6) {gf_global["number_formats"][6] = {"1":{"price":false,"value":false},"2":{"price":false,"value":false},"7":{"price":false,"value":false},"20":{"price":false,"value":false},"15":{"price":false,"value":false},"19":{"price":false,"value":false},"22":{"price":false,"value":false},"10":{"price":false,"value":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][6] = { logic: { 10: {"field":{"actionType":"show","logicType":"any","rules":[{"fieldId":"22","operator":"is","value":"Yes, I love mail!"}]},"nextButton":null,"section":null} }, dependents: { 10: [10] }, animation: 1, defaults: {"1":{"1.2":"","1.3":"","1.4":"","1.6":"","1.8":""},"15":["choice_6_15_1"],"10":{"10.1":"","10.2":"","10.3":"","10.4":"","10.5":"","10.6":""}}, fields: {"1":[],"2":[],"7":[],"20":[],"15":[],"19":[],"22":[10],"10":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(6, [10], true);jQuery('#gform_wrapper_6').show();jQuery(document).trigger('gform_post_conditional_logic', [6, null, true]);} );} gformInitChosenFields('#input_6_7','No results matched');} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){gformInitChosenFields('#input_6_7','No results matched');} );</script><script type='text/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [6, 1]) } ); </script>
MENU