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Obtaining a full-mouth series of dental radiographs can seem daunting for many veterinary technicians, especially in hospitals that do not incorporate the practice into daily routines. The easiest and fastest way to master the techniques required to produce diagnostic-quality radiographs is through in-person professional training. A veterinary technician with specialty certification in dentistry is a true expert with the education and experience to help your team succeed without the fear and frustration of practicing on anesthetized patients (

). In addition to helping your team learn the simplest positioning techniques, this person can help ensure that all team members are on the same page regarding client education, workflow during procedures, and interpretation of the images once obtained.

Training for dental radiography is best done on specimens or bone skulls to ensure a quality learning experience without the stress of caring for a live animal. We learn best from our mistakes; however, let’s not make them with a patient under anesthesia if at all possible.

Obtain the full-mouth series of radiographs early in the procedure, immediately after the patient is anesthetized and stabilized. Doing so helps get the diagnostic process started with some objective data.

Once you have the radiographs, you will likely find more pathology and need to call the client for treatment approval. If you wait to obtain radiographs until everything else is done with the patient’s mouth and the client doesn’t answer when you call for treatment authorization, the patient’s time under anesthesia may be extended unnecessarily.

Patients should be positioned in the same way each time a radiograph is obtained. With sternal and dorsal head positioning, ensure that the patient’s hard palate is parallel to the tabletop (

). If you wish to obtain the radiographs with the patient in a lateral head position, make sure the hard palate is perpendicular to the table. I prefer to obtain full-mouth dental radiographs with the patient initially in sternal positioning for the maxillary views and then in dorsal recumbency for the mandibular views.

Achieving consistent results can be very challenging if you are not using these specific patient head positions. If the patient’s head is oblique (not straight), you must position the beam using bisecting angles, a method many find troublesome, time-consuming, and prone to error.

Don’t depend on any one view to determine the presence or absence of pathology if something seems questionable. When you are unsure about what you may be seeing, obtain a second or even third view from a different horizontal perspective than the original survey view of that tooth or area.

Analgesia and anesthesia are critical when obtaining dental radiographs. Make sure the patient is adequately premedicated and then maintained under a surgical plane of general anesthesia (ie, unable to respond to stimuli) for the entire procedure.

Avoiding sensor damage involves having an exceptional understanding of analgesic principles and how to determine a patient’s depth of anesthesia properly, observing constantly and adjusting depth accordingly while preventing hypotension and other complications. Do not place the sensor in the mouth of a patient that is not fully anesthetized and intubated.

A patient’s jaw tone and reflexive mouth closure can cause significant destruction of the sensor. To avoid sensor damage, particularly by dogs, wedge a bite-block object—such as an old section of endotracheal tube (larger size for dogs) or a dental wedge—between the molars on at least 1 side of the mouth. This will prevent an unexpected bite down by the patient (

Once you have training and a repeatable technique, your speed will improve. But at first, prioritize technique over speed. Dental radiographs must contain the tooth or teeth and bone surrounding them as desired; there must not be elongation or foreshortening distorting bone or tooth. Some parts of mouth (eg, tooth root, alveolar bone) cannot be seen with the naked eye. These, in particular, are of the utmost importance. With practice, you will be able to expose about 1 image per minute and, with daily practice on every dental patient, every time, you will become even more efficient and consistent.

It’s important to have a thorough understanding of what can cause problems when obtaining dental radiographs. This comes down to 3 variables, which I call the ABCs: A—animal, B—beam, and C— sensor, phosphor plate, or film.

The operator must objectively measure each of the 3 ingredients in the formula to get consistently diagnostic radiographs. When you get an image that isn’t diagnostic, ask yourself what caused the error. Was it the animal’s head position (A), the beam’s angle or rotation (B), or the sensor’s location in the mouth (C)? When you determine what caused the issue, fix that and try again (

The bottom line Learning dental radiography is challenging, but don’t give up. Becoming proficient involves at least 1 serious learning opportunity, practice without added stress or pressure from your team, and ongoing evaluation of what is working well and what you still need to learn and practice more.

Benita Altier, LVT, VTS (dentistry), began her business, Pawsitive Dental Education, with the goal of bringing professional dental instruction to veterinary hospitals and conferences across the United States and Canada. She currently resides in Washington. 

Articles

To consistently obtain diagnostic intraoral radiographs, keep these important points in mind.

Tips for mastering veterinary dental radiography

This week, we will be posting a wide array of veterinary news content including:

the second levothyroxine sodium product approved as replacement therapy for diminished thyroid function in dogs.

An article detailing everything you need to know about #veterinary relief work.

A new article about how to enhance curbside care protocols.

Stay tuned to dvm360.com to stay up to date with the latest industry news.

This week on dvm360: A new FDA approval, plus more veterinary news

Years ago, I took a hiatus from clinic ownership. I sold my practices to spend more time with my young family. I did not want to exit clinical work entirely but wanted to regain control of my schedule in hopes of seeing more kid baseball games and planning trips to amusement parks. So, I became a relief veterinarian. Was I in for a surprise. I placed a small classified ad in the state veterinary society magazine and, before I knew it, I had more relief gigs than I could handle. I soon discovered that relief veterinary work is a great way to earn a living. But to prosper and avoid big problems, you must be smart.

The significance of a relief service contract

Plenty of relief veterinarians think gig worker status is based on a simple arrangement between the veterinarian offering occasional services and the clinic that responds. Legally, 4 parties are involved, and each has its own interest. Of course, there are the relief veterinarian and the clinic owner—the former wanting the highest price per shift, and the latter the lowest possible cost per day for the services.

But 2 other partners—the Internal Revenue Service (IRS) and state government—have perpetual needs that must be recognized and satisfied. Both want the same thing from the relief doctor and the clinic owner: regulatory compliance.

I quickly recognized during my brief gig career that perhaps the only way to satisfy all 4 parties was to have a written contract between the relief provider and the clinic for which the veterinary work would be done. Consider these risks of not formalizing the relief services relationship in this way.

Unless the relief practitioner requests and receives payment at the end of each shift, there is an underlying risk that a clinic may later neglect or refuse to pay for past services. This is particularly likely if there has been a misunderstanding (unintentional or not) about work schedule, pay rate, or whether lunchtime is compensated. Sometimes, the practice owner runs short on money. Without a written service agreement, such disputes end up in court, possibly leaving the gig veterinarian on the losing side.

In the absence of a written agreement, unanticipated disputes can arise regarding whether commuting time is included in the provider’s hourly rate calculation and whether a fee will be charged for mileage (and the amount per mile). Does the relief veterinarian get paid hourly to make phone calls at the end of a shift, or does payment cease at the end of the final appointment? All these questions can be resolved in advance with a well-crafted relief contract.

Relief veterinarians play a vital role in clinic scheduling. They enable owners to take personal time, and they soften the blow when an associate is on family leave or exits the hospital unexpectedly. No clinic owner wants to sour a relationship with a good, reliable relief veterinarian. But in the absence of a clear contract, the relief doctor/clinic owner relationship can suffer as unanticipated disagreements arise.

Sometimes hourly per diem veterinarians linger long after office appointments end, making more and longer phone calls on the clock than the practice owner feels are necessary. Occasionally the owner or medical director can attempt to micromanage cases being handled by the fill-in veterinarian. I have seen instances where a practice and per diem doctors clash over dress (too casual?), footwear (slip and fall/Occupational Safety and Health Administration violation risk?), and even inappropriate lunch hour sunbathing between morning and afternoon appointments. Relief contracts can address any such issues from the outset of the worker-owner relationship.

The IRS is interested in your contract—or lack thereof

The IRS loves employees—independent contractors, not so much. In fact, the agency considers everybody not an owner to be an employee until proved otherwise. If a relief veterinarian wants to carry out services as an independent contractor, it means an obligation to demonstrate that they are not an employee under law. With a solid written relief services contract that fully describes the business relationship, this obligation is much easier to satisfy.

The contract terms help clarify reasons relief veterinarians may appropriately consider themselves nonemployees. The IRS prefers individuals to be considered employees because the agency tends to get its withholding money from each paycheck right away, before the worker ever gets paid. The same goes for the worker’s required Federal Insurance Contributions Act (FICA) and Medicare contributions.

Independent contractors, on the other hand, generally receive payment for services in lump sums without any immediate withholding. Rather, they are charged with meeting several tax compliance obligations, including making estimated tax payments. The federal government doesn’t like having to risk chasing down independent contractors who sometimes spend funds owed to Treasury or Social Security Administration.

Therefore, if a relief veterinarian pursues a gig career without strictly adhering to the characteristics of an independent contractor, the federal government may and can impose financial penalties against him and any clinic that inappropriately failed to withhold and remit taxes, FICA contributions, and Medicare payments from the relief veterinarian’s earnings.

However, clarifying language can be included in a relief contract to reinforce the notion that the occasional worker is indeed an independent contractor. This includes clear statements explaining how the job was obtained, whether the worker is paid commission (aka production), whether services are provided on the same schedule each week, and whether the worker provides their own instruments and equipment. (For more detailed information about the characteristics of an “independent contractor,” refer to 

 per www.irs.gov/pub/irs-pdf/fss8.pdf to provide guidance.)

The existence of a written agreement between a per diem or shift veterinarian and a clinic is persuasive if IRS seeks details of the relief client/contractor relationship.

Naturally, state tax authorities are interested in the “contractor or employee” nature of a relief veterinarian in states that have an income tax. But even states like Florida and Texas, which do not have income tax, want to know who in the work relationship is tasked with providing regulatory compliance over the worker/owner arrangement.

If you are an employee, your boss is charged with making sure you are covered by a workers’ compensation policy. In the absence of a relief contract, that issue may be neglected, with the owner later discovering that failure to cover the per diem doctor constituted a violation of the law.

The same problem exists regarding statutory unemployment insurance filing and remittance laws. And don’t forget about legally required disability insurance payments.

Written relief contracts are good insurance

The general rule I recommend that relief veterinarians follow is this: If you are doing a limited amount of relief work, request that your employer pay you according to a written contract, but as an employee, not an independent contractor. The contract will cover the items that could otherwise result in a disagreement, but the W-2 worker status will keep everyone paying and reporting to the federal, state, and municipal governments as they should.

I suggest that for veterinarians making gig work a primary occupation, a contract also be used, but that it additionally include as much detail as possible to support the argument that independent contractor status—if sought—is firmly supported in writing and with formality.

Christopher J. Allen, DVM, JD, is the president of Associates in Veterinary Law, PC, which provides legal and consulting services exclusively to veterinarians. He can be reached at info@veterinarylaw.com. Allen serves on the dvm360® Editorial Advisory Board.

One veterinarian shares the ins and outs of relief work, plus what to look for in your contract agreement.

Relief veterinary work: What you need to know

The FDA has announced the approval of ThyroKare (levothyroxine sodium tablets, Neogen Corp), a replacement therapy for hypothyroidism in dogs.

Hypothyroidism is a common hormone imbalance in which progressive destruction of the thyroid gland leads to diminished thyroid function and insufficient thyroid hormone levels. The condition is typically seen in middle-aged to older dogs and occurs more commonly in medium to large breeds.

, the safety of ThyroKare in dogs was established based on several sources, including a comprehensive literature review on the use of levothyroxine in dogs; pharmacovigilance data voluntarily reported to the sponsor when the drug was previously marketed as an unapproved drug, and reports of accidental overdoses of natural or synthetic thyroid hormone products in dogs.

Both safety and effectiveness of ThyroKare were demonstrated in a field study in client-owned dogs. Owners of dogs that had been diagnosed with hypothyroidism but never treated with levothyroxine sodium were dosed with ThyroKare orally twice daily at home. On day 84, 87 of 107 study dogs (81.3%) evaluated for effectiveness were considered a treatment success based on thyroid hormone levels. On day 168, the same number of dogs were considered a treatment success, although the cases considered successes were not necessarily the same at both time points.

Clinical signs of hypothyroidism also improved during the study. The most common adverse reactions were polyuria/polydipsia, tachypnea, lethargy, anorexia, vomiting, and muscle tremors or shaking.

ThyroKare is available by prescription only. The starting dose is 0.1 mg/10 lb (0.01 mg/lb, 0.022 mg/kg) body weight twice daily. To minimize day-to-day variations in serum total thyroxine concentrations, ThyroKare should be administered consistently either with or without food.

Monitoring typically includes regular evaluations of thyroid hormone levels to ensure the prescribed dose of the product remains at an appropriate level to manage the disease. Monitoring is also important when switching to another levothyroxine sodium product due to potential differences in recommended doses and in bioavailability.

ThyroKare is available in 9 strengths of color-coded tablets ranging from 0.1 to 1 mg, in bottles of 180- and 1000-tablet counts.

ThyroKare is the second levothyroxine sodium product approved as replacement therapy for diminished thyroid function in dogs.

FDA approves new therapy for canine hypothyroidism 

As we continue to adjust to these unprecedented times, we will continue to keep you updated with the latest pandemic news and our coverage of the veterinary industry.

The US Food and Drug Administration announced on Monday, the conditional approval of Laverdia-CA1 (verdinexor tablets), 

The FDA announced earlier this week that Midwestern Pet Foods, Inc 

has significantly expanded its recall of Sportmix brand pet foods

 due to potentially elevated levels of aflatoxin.

 Standards & Policies for new PAVE for Veterinary Technicians

, a program designed to assess the education equivalence of global veterinary technician/nurse graduates. 

, Tom Seeko, cofounder of Florida Veterinary Advisors, talks with Dr. Christman about the 4 key elements to maximizing your veterinary practice.

Here's a look at this week's top news stories. 

News wrap-up: This week's veterinary headlines, plus an alarming pet food recall expansion

The US Food and Drug Administration announced yesterday the conditional approval of KBroVet-CA1 (potassium bromide chewable tablets, Pegasus Laboratories Inc) to help manage seizures in dogs with idiopathic epilepsy.

 treatment to be granted under the reauthorized 

stabilizes neurons in the central nervous system to reduce the chances of having a seizure. Available by prescription only, KBroVet-CA1 is administered orally daily.

Potassium bromide has long been used to control canine seizure disorders. However, prior to the FDA’s new authority, no veterinary drug sponsor had applied for approval.

“We are pleased to see animal drug sponsors respond to the expanded conditional approval authority by bringing forward applications to treat serious, life-threatening diseases for which there are no approved therapies available,” says Steven M. Solomon, DVM, MPH, director of the FDA’s Center for Veterinary Medicine, in this 

Conditional approval, which is an option for drugs intended for minor use in major species, provides veterinarians with access to necessary treatments while the pharmaceutical company gathers additional efficacy data.

The expanded authority allows for the conditional approval of drugs intended to address “a serious or life-threatening disease or condition, or an unmet health need, but for which demonstrating effectiveness would require complex or particularly difficult studies,” according to the release.

Initial conditional approval is valid for 1 year with the potential for 4 annual renewals. During this period, the drug sponsor must demonstrate that it is actively working toward collecting the remaining effectiveness data to support full approval.

KBroVet-CA1’s reasonable expectation of efficacy was demonstrated in a retrospective study of the medical records of 51 client-owned dogs with idiopathic epilepsy, all of whom were treated solely with potassium bromide at the same dose for at least 60 days to control their seizures.

, the most common adverse reactions associated with potassium bromide administration are neurologic (including behavioral changes), gastrointestinal (including inflammation of the pancreas), reproductive, endocrine, dermatologic, and respiratory. Increased thirst and urination may also occur. Dogs with decreased kidney function appear to be at greater risk for bromide intoxication, the signs of which can include depression, behavioral changes, ataxia, hind limb paresis, mydriasis, stupor, and coma.

The FDA advises owners of dogs with idiopathic epilepsy to work closely with their veterinarians to monitor clinical signs to help control potential seizures that may result from bromide intoxication. The agency also recommends avoiding abrupt diet changes in dogs receiving potassium bromide, as this could compromise seizure control or raise safety concerns.

KBroVet-CA1 is available by prescription only. 

KBroVet-CA1 reduces the likelihood of seizures by stabilizing neurons in the central nervous system.

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