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If you’ve been in clinical practice for more than a few weeks, you’ve probably worked with at least 1 retail pharmacy. Sometimes providing a script to an outside pharmacy is a necessity when your practice does not have the medication in stock. Other times, a client requests a prescription because the medication likely costs less at a retail pharmacy. According to the American Veterinary Medical Association (AVMA), veterinarians should honor all client requests for a written prescription.

Many clients are unaware of the headaches associated with these prescriptions, or the errors that may occur when a prescription is filled by a retail pharmacy. In 2012, the Oregon Veterinary Medical Association released the results of a survey investigating outcomes when veterinarians scripted medications to both online and brick-and-mortar retail pharmacies. Of the veterinarians surveyed, 35% had experienced an instance in which a retail or online pharmacy changed a prescribed dose or changed the medication itself without contacting the prescribing veterinarian, with 16.5% reporting that these changes led to adverse effects for the patient.

 Understanding why these problems arise and building relationships with pharmacists in your community can help to improve outcomes for your patients.

Why conflicts arise between veterinarians and pharmacists

Just as veterinarians are bound by ethical and legal obligations that govern the practice of veterinary medicine, pharmacists have professional requirements to which they must adhere. Pharmacists are legally required to verify the accuracy and validity of each prescription they fill, and to advise clients about potential side effects and drug interactions. For medications intended for people, this is simple to do because pharmacists have the knowledge and resources to fulfill these requirements. Unfortunately, pharmacists do not receive training in veterinary pharmacology as part of their core curriculum. This opens the door for error because for some drugs large differences exist between humans and animals with regard to in dosing and side effects.

Although it is easy to say that pharmacists should receive more education and have access to veterinary pharmacology resources, making this a reality is not so simple. The AVMA and National Association of Boards of Pharmacy (NABP) have worked together to increase awareness of the problems for both veterinarians and pharmacists and encourage the addition of veterinary pharmacology education to pharmacy school curricula.

The NABP has also modified its model practice act to add a requirement that a veterinary drug reference be available in any pharmacy where veterinary medications are dispensed.

 To date, only a handful of states have implemented this recommendation. If you are in a state that does not currently require a veterinary drug reference to be on hand in pharmacies filling pet medication prescriptions, consider reaching out to your state veterinary medical association. Encourage them to start a conversation with the state pharmacy board and advocate for this change.

Tips for building working relationships with community pharmacists

The AVMA’s Pharmacy and Prescription Resource Center offers detailed information about reducing prescription errors, writing prescriptions, compounding, pharmacy complaints, e-prescribing, clients education and more. Visit 

avma.org/resources-tools/animal-health-and-welfare/animal-health/pharmacy

To report a pharmacy error to the AVMA, visit 

avma.org/sites/default/files/resources/complaint_form.pdf

A recent survey of veterinarians and pharmacists in Ohio found that members of both professions felt that interprofessional collaboration was important to optimizing outcomes for veterinary patients.

 Sometimes, veterinarians become overwhelmed when working with pharmacies, developing a negative outlook on collaboration because of previous experiences. Here are several ways you can establish productive working relationships with pharmacists in your area:

Open the lines of communication with local pharmacies by visiting them or sending a letter (the AVMA has a sample letter available at 

). Introduce yourself and express your desire to work with the pharmacy for the best possible veterinary patient outcomes. Encourage the pharmacy team to contact you with any questions regarding pet prescriptions.

Donate an old copy of your favorite veterinary drug reference to your local pharmacy. Doing so may decrease the number of phone calls you receive from pharmacists.

Provide handouts for pharmacists that can serve as a quick reference guide on common toxins (eg, xylitol, acetaminophen) and prescription concerns (eg, changes in insulin type, thyroid medication doses).

Maintain patience when pharmacists do call with questions. Use these conversations as a chance to educate pharmacists and encourage them to continue calling.

Educate pharmacies about identification numbers. Many pharmacies will call asking for a national provider identifier (NPI) or Drug Enforcement Agency (DEA) number to fill a prescription. (The NPI is an identification number used for Medicaid patients.) Instead of saying “I don’t have an NPI number, and I won’t provide a DEA number for noncontrolled substances,” consider letting the pharmacist know 

 you don’t have an NPI and that the DEA opposes the use of a DEA number for identification purposes.

Always provide clear prescriptions. Written prescriptions are the best way to reduce miscommunication. Typed prescriptions are preferred, but legible, hand-written prescriptions are acceptable. Write out the entire prescription and avoid using abbreviations such as SID (once daily), which are not used in human medicine. Specify “no substitutions” when applicable, and write “must not contain xylitol” when prescribing suspensions, orally disintegrating tablets, and human chewable tablets.

Reach out to local pharmacy groups or schools and offer to provide a lecture on veterinary prescriptions.

Even with relationship building and improved education, errors may still occur. In these cases, it is important to reach out to the pharmacy to advise them of the error and discuss how to avoid the same error in the future. Additionally, errors can be reported to both the AVMA and the state pharmacy board.

Ultimately, it will take both veterinarians and pharmacists working together to improve the situation and prevent errors. Problems with pharmacies are common and frustrating for veterinary teams, but we encourage veterinarians to take the first step toward bettering working relationships. Neither the veterinarian nor the pharmacist wants to see a patient harmed, but it is only by working together that we can reduce conflict and maximize patient safety.

Kate Boatright, VMD, a 2013 graduate of the University of Pennsylvania, is an associate veterinarian and freelance speaker and author in western Pennsylvania. She is actively involved in organized veterinary medicine at the local, state, and national levels and is a former national officer of the Veterinary Business Management Association.

Lauren Forsythe, PharmD, DICVP, is a licensed pharmacist who is board certified in veterinary pharmacy. She has worked in retail pharmacy and currently supervises the pharmacy at the Veterinary Teaching Hospital at the University of Illinois.

1. Principles of veterinary medical ethics of the AVMA. American Veterinary Medical Association. August 2019. Accessed October 3, 2020. https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma

2. Kolb G. Veterinary prescriptions & retail pharmacies summary of membership survey

 Oregon Veterinary Medical Association. September 2012. Accessed October 3, 2020. https://www.ftc.gov/sites/default/files/documents/public_comments/request-comments-and-announcement-workshop-pet-medications-issues-project-no.p121201-560891-00569/560891-00569-84588.pdf.

3. Regulators and stakeholders explore means to support safe dispensing of pet medications by community pharmacies. 

 2013;42(7):145-147.https://nabp.pharmacy/wp-content/uploads/2016/08/August_2013_NABP_Newsletter.pdf

4. Updated Model Act Available; Amended Language Addresses Timely Pharmacy Practice Topics. Newsletter NABP 44(8):157-158.

5. Fredrickson ME, Terlizzi H, Horne RL, Dannemiller S. The role of the community pharmacist in veterinary patient care: a cross-sectional study of pharmacist and veterinarian viewpoints. 

https://doi.org/10.18549/PharmPract.2020.3.1928

6.Inappropriate requests for Drug Enforcement Agency (DEA) registration numbers. American Veterinary Medical Association. Accessed October 3, 2020. 

https://www.avma.org/resources-tools/avma-policies/inappropriate-requests-drug-enforcement-administration-dea-registration-numbers

Articles

Veterinarians are keenly aware of the errors and frustrations that can occur when working with a retail pharmacy. Building relationships with pharmacists can help improve patient outcomes.

Why—and how—to build relationships with community pharmacists

How many of us have heard owners talk about their dog “slowing down”? “He’s just getting older,” they often say. Yet, according to Amber Ihrke, DVM, CCRT, CVA, CVSMT, CAC, CVPP, owner and medical director of Integrative Pet Care of Homer Glen in Homer Glen, Illinois, age alone does not cause pets to slow down. Instead, slowing down is a manifestation of underlying disease, and it is important to find the true cause and address it.

Commonly, the underlying cause is osteoarthritis (OA). OA affects 1 in 5 adult dogs and is the leading cause of chronic canine pain.

 It can lead to decreased quality of life, reduced performance and activity and, in some cases, eventual euthanasia. Ihrke told attendees at the American Veterinary Medical Association Virtual Convention that it is important to intervene before end-stage joint degeneration—preferably as soon as a patient’s activity level starts to decrease.

Ihrke first reviewed a bit about the pathophysiology and progression of OA.

 First, pathologic changes occur in the articular tissues, commonly manifested by thickened joint capsules. The synovial membrane then becomes inflamed, and the synovial fluid less viscous. Pain begins at this stage as a result of synovial inflammation, and it is during these early stages that intervening offers the most benefit. The next phase is cartilage deterioration. Finally, osteophytes develop and bone remodeling occurs. This mechanical failure of articular cartilage is the defining element of OA and is irreversible.

 No risk factors, patient is clinically normal

 At-risk dogs; clinical signs are difficult to detect, but physiologic factors of OA are present

 Mild OA; clinical signs are intermittent and include obvious impairment of the ability to perform certain daily activities, consistent alterations in body carriage, and muscle loss

 Moderate OA; patient has constant impairment of form and a diminished capacity to engage in activities of daily living

 Severe disease; mobility is impaired, and the patient’s ability to move or jump is decreased compared with previous normal activity

Clinical disease caused by these pathophysiologic changes can be quantified using the Canine OsteoArthritis Staging Tool (COAST), which categorizes OA into 5 stages (see 

 Owners typically start noticing reduced activity in their pets during stage 2, and patients are presented for evaluation most commonly during stage 2 or 3.

Before we can develop a treatment protocol, Ihrke said, we need to confirm the diagnosis. A thorough and systematic patient evaluation is important and should not be overlooked. This includes signalment (to help guide the differential diagnosis), a thorough history, gait assessment, physical examination, and diagnostic tests. The history should include detailed questions about the pet’s ability to perform various daily activities (eg, getting into and out of their bed, going up or downstairs, walking around the yard).

“It’s important to compare the pet’s current and past activity levels,” Ihrke said. “Knowing that a patient can walk 1 mile at the time of evaluation is a seemingly good sign, but it can be misleading if a couple months earlier the pet was able to walk 2 or 3 miles.” Additionally, be sure to establish whether the patient is a pet versus a performance animal.

When evaluating gait, do so in several situations, and from multiple directions, Ihrke advised. Assess the patient as they walk casually around the exam room and when moving on a leash at both a walk and a trot. Transitions from 1 position to another (eg, rising from lying down) can be telling, but these actions must be voluntary and without manual interference. Ihrke recommends using video recordings where possible and said use of a lameness scale is essential. “Many scales are available and will help objectively compare findings from 1 visit to the next, or assess accurately when evaluations are done by more than 1 associate,” she said. Importantly, the owner can conceptualize improvement more easily when they can see progress on a quantified scale.

The physical examination is clearly essential. The crepitus, range of motion, effusion, pain, instability (CREPI) system for joint evaluation provides a systematic approach.

 Palpate both sides of the patient, starting with the presumed unaffected areas. Assess muscle atrophy, joint swelling, asymmetry, muscle tenderness, and heat. The goal of the examination is to confirm the area of lameness and lead you toward a diagnostic plan. Much like a scoring system for gait is essential, a pain score is similarly important. The diagnostic plan would then include case-appropriate modalities, such as orthogonal radiographs and joint taps.

Ihrke presented a list of 5 management goals for dogs with OA:

These goals are best accomplished, she said, using a multimodal and comprehensive approach.

One of the starting points of treatment is nonsteroidal anti-inflammatory drugs. Adjunctive therapies such as amantadine, amitriptyline, or gabapentin (or combinations thereof) may also be used. Disease-modifying agents such as polysulfated glycosaminoglycans may also be beneficial and are commonly used. Omega-3 fatty acid supplements, chondroprotective supplements, and diets rich in eicosapentaenoic acid are also beneficial.

Ihrke sais this term is often better received by owners than “weight loss” or “diet,” and can have a great impact. Weight loss of 6.10% has been associated with a subjective decrease in lameness, and improvement on kinetic gait analysis can be seen with a weight loss of 8.85%.

 As such, her goal for patients is a standard 10% reduction in body weight, as weight optimization alone may help reduce clinical signs of OA.

Rehabilitation is part of the multimodal approach, but in itself is also multimodal. Environmental modifications to improve traction in the home (eg, carpet, yoga mats, booties) is 1 component. There are also many therapeutic aids, in addition to manual therapy. Thermotherapy employs a combination of cold packs (to reduce acute-phase inflammation) on affected joints, with hot packs (to increase blood flow, improve connective tissue extensibility, and promote muscle relaxation) on soft tissues in the surrounding regions. Other therapies include transcutaneous electrical nerve stimulation, which provides pain relief and can be used at home; photobiomodulation (therapeutic laser); hydrotherapy, which can reduce the load on hip joints by 60% when water is at hip level; therapeutic ultrasound; pulsed electromagnetic field therapy; and extracorporeal shockwave therapy. All of these modalities are used to reduce pain and inflammation or improve muscle relaxation and mobility. As such, some may be targeted to the affected joint and others on the adjacent muscle groups.

Manual therapy remains the most essential aspect of rehabilitation. “Above all other rehabilitation tools, manual therapy is always a component—and the cornerstone—of the treatment protocol,” Ihrke said. Manual therapy includes releasing trigger points, improving joint range of motion, and decreasing pain through massage.

The second most important aspect of the rehabilitation protocol is a therapeutic exercise program. “Fitness in dogs is not achieved via self-directed activities,” Ihrke said. “Walking around the yard is not the same as an intentional plan to target a specific group of muscles or a specific movement.”

Much like rehabilitation aids can be used to improve a patient’s pain control or function, intraarticular injections (eg, hyaluronic acid or corticosteroids) may do the same. These are administered on a case-by-case basis and are always prescribed alongside a corresponding rehabilitation plan. Further, intra-articular injections of platelet-rich plasma or stem cells may have a role in the future, particularly in early OA.

All of these aspects of evaluation and treatment circle back to setting goals for the patient. The goals set by a clinician must take into account the goals of the owner and the role of the patient (whether it is a pet, working dog, or performance dog). If the owner’s goals are unrealistic, have a discussion to reach a reasonable consensus. Ihrke advised setting SMART goals with clients: specific, measurable, attainable, relevant, and time-based. An example of a SMART goal is to improve weight-bearing of the right pelvic limb by 15% (relevant, measurable, and specific) in 4 weeks (time-based and attainable).”

Ihrke’s comprehensive patient evaluation plan includes signalment, a thorough patient history, gait evaluation, physical examination, and diagnostic testing. A multimodal treatment protocol, including medications, weight optimization, supplements, and rehabilitation, is best implemented in the earliest stages of joint progression when possible. In this way, we can provide the most benefit to dogs suffering from OA that need our help to maintain a favorable quality of life.

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.

1.Johnston SA. Osteoarthritis. Joint anatomy, physiology, and pathobiology. 

. 1997;27(4):699-723. doi:10.1016/s0195-5616(97)50076-3

2. Fox SM. Multimodal Management of Canine Osteoarthritis. CRC Press; 2017.

3.Introducing a logical, comprehensive staging tool for canine osteoarthritis. American Animal Hospital Association. November 1, 2019. Accessed October 14, 2020.

https://www.aaha.org/publications/newstat/articles/2019-11/introducing-a-logical-comprehensive-staging-tool-for-canine-osteoarthritis/

4. Roe SC. Diagnosis and conservative management of joint disease. Paper presented at: 32nd Congress of the World Small Animal Veterinary Association Proceedings; August 19-23, 2007; Sydney, Australia. Accessed October 14, 2020. 

https://www.vin.com/apputil/content/defaultadv1.aspx?meta=Generic&pId=11242&id=3860763

5.Marshall WG, Hazewinkel HA, Mullen D, De Meyer G, Baert K, Carmichael S. The effect of weight loss on lameness in obese dogs with osteoarthritis. 

. 2010;34(3):241-253. doi:10.1007/s11259-010-9348-7

Early recognition of degenerative joint disease combined with a multimodal treatment approach that includes a comprehensive rehabilitation plan can improve patient outcomes.

Rehabilitation and canine osteoarthritis: a multimodal approach

The serious nature of spleen removal surgery is often overlooked. Perhaps the fact that dogs can function well without the organ is partly to blame. Or maybe, as posited by Harry W. Boothe, DVM, MS, DACVS, professor emeritus of soft-tissue surgery at Auburn University College of Veterinary Medicine, it’s because for many years it wasn’t unusual for veterinary schools to use the procedure in junior surgical laboratory settings as an exercise in knot tying and ligation placement.

Years of experience have taught Boothe to see the surgery a little differently. He says that while splenectomies are often straightforward and predictable, he has been a part of many surgeries that haven’t fit that neat and tidy mold— both peri- and postoperatively. “There are a lot of things we don’t understand about the spleen,” Boothe explained during a session at the Fetch dvm360® virtual conference in August, “not the least of which is the 

cause of cardiac arrhythmias being associated with splenic masses, splenic enlargement, and splenectomies.”

Boothe began with a quick refresher on splenic anatomy. The spleen, he said, is suspended by the greater omentum and attached to the greater curvature of the stomach by the gastrosplenic ligament. The splenic artery arises from the celiac artery, which is the first branch of the abdominal aorta and divides into multiple smaller hilar branches before entering the spleen.

“In addition to supplying the spleen, the splenic artery supplies the left pancreatic limb," Boothe said. That pancreatic limb that lies caudal and parallel to the stomach is a lot closer to the spleen than I think we often realize—or at least the blood supply is. And I think part of
my concern with some of the minimal ligation techniques is that, particularly with splenic hilar disease, we could be a lot closer to embarrassing blood supply to the left pancreatic limb then we realize.”

Boothe added that it is important to remember that although the splenic veins parallel the splenic artery, they enter the portal vein, not the caudal vena cava. “We can use them to access the portal venous system and to evaluate portal venous pressures,” he explained.

There are several reasons for removing a patient’s spleen, including lesions and trauma. Boothe focused first on splenic torsion, explaining that the condition occurs when the spleen rotates around its vascular pedicle, resulting in venous obstruction and subsequent splenomegaly.

True to the textbooks, Boothe has seen splenic torsion consistently in large- and giant-breed dogs with deep-chested conformations. “In my experience, it’s usually an isolated event, meaning it’s not necessarily associated with trauma or other situations." But, he said, “we always look for splenic torsion in association with gastric-dilatation volvulus.”

Boothe explained that there are 2 possible presentations for dogs with splenic torsion: acute and chronic. Abdominal pain and collapse are common acute presentations, while vomiting, anorexia, intermittent abdominal pain, abdominal distension, polyuria, and polydipsia characterize chronic cases. “I can recall a case with chronic presentation that did very poorly following splenectomy,” said Boothe. “I think time is some- what of the essence in dealing with presumed or documented splenic torsion.”

With regard to laboratory results, Boothe said hemoglobinuria may be noted on urinalysis in chronically presenting patients and that hematologic findings often include anemia, thrombocytopenia, and leukocytosis.

While abdominal radiography and ultrasonography are often part of getting to a diagnosis, Boothe said he could probably argue that you can't definitively diagnose splenic torsion based on radiographs alone. Abdominal ultrasound, however, particularly with Doppler flow capabilities, is an excellent diagnostic tool in splenic torsion cases. "Findings often include generalized splenomegaly, evidence of splenic infarction, a twisted splenic pedicle, and absence of blood flow through the splenic vessels on Doppler evaluation," Boothe explained. Still, he said, it's not uncommon for the definitive diagnosis to be made at the surgery table through exploratory laparotomy. 

Complete spleen removal is the treatment of choice for dogs with splenic torsion. Boothe said if you can perform surgery in a timely fashion, you will typically just see splenic engorgement with a twisted pedicle once your patient reaches the operating table. "But if it's been more of a chronic situation with a delay in getting to surgery," he continued, "there may be evidence of venous thrombosis and the possibility of necrosis." Necrosis tends to correspond with worse outcomes, he said.

Because Boothe knows that the patient’s splenic tissue may be friable, making simple attempts at exteriorization potentially insulting to the patient, he approaches the situation with what he calls a somewhat old-school plan that’s become his default. First, he confirms the location of the left pancreatic limb. Then, he uses 1 or 2 large-diameter sutures (eg, #1 polydioxanone) to ligate the entire splenic vascular pedicle before removing the spleen in its twisted state.

With the spleen out, Boothe slowly untwists the pedicle, 

examines it for hemorrhage, and places additional ligatures or uses a high-energy sealing device as needed. “Now, one could argue that high-energy sealing devices could be used to work through the pedicle in its twisted state and deal with it that way,” he said, “but I think that sometimes it’s easier and quicker to get the spleen out and then deal with the pedicle as a separate structure.”

Because delayed hemorrhage is a possible postoperative complication, Boothe is careful to ensure that the vascular pedicle isn’t bleeding before closing the patient’s abdomen and performing intraoperative peritoneal lavage to evacuate the hemorrhagic effusion.

Don’t miss a beat (particularly the irregular ones)

Remember those mysterious postoperative cardiac arrhythmias associated with splenectomies? Boothe does too, which is why he recommended that splenectomy patients recover for 2 to 3 days after surgery at a 24-hour care facility or in a setting with overnight monitoring—"not necessarily with continuous heart monitoring," he explained, "but just to make sure we’ve got good perfusion, good mentation, and good recovery from the procedure.”

Sometimes, splenectomies are straightforward and predictable. Other times, not so much. A veterinary surgeon shares tips for getting better outcomes in splenic torsion cases.

Let’s undo the twist: diagnosing and treating splenic torsion in dogs

Sometimes waiting to perform treatment is the best course of action when a patient presents with dental concerns, as noted in the August issue of dvm360® (“

The ABCs of veterinary dentistry: W is for waiting to treat

”). But other times waiting is simply not an option—the patient’s problem needs to be addressed immediately.

Dogs should have 42 permanent teeth, cats 30. If 1 or more teeth are not present clinically, it is time for detective work This involves examining intraoral radiographs to determine whether a tooth is present subgingivally and, if so, whether a pathologic process (periapical lucency) is at play that needs immediate care. Waiting to diagnose and treat can lead to progression of subgingival pathology in these patients (

When a patient presents with persistent primary teeth—primary (baby) and secondary (adult) teeth present clinically in the same alveolus—immediate extraction of the primary tooth is indicated. Persistent primary teeth may overcrowd the dental arch, moving the secondary teeth to abnormal locations and causing oral discomfort. Double sets of roots may also prevent normal development of the alveolus and periodontal support around each permanent tooth, leading to early tooth loss.

A persistent primary tooth should be extracted as soon as the permanent tooth is observed to erupt in the same alveolus. When extraction is performed early, the abnormally positioned permanent tooth ideally moves into normal position. Extraction must be done carefully to avoid accidental damage to the unerupted, permanent canine tooth that lies lingual to the mandibular teeth and rostral to the maxillary deciduous canines. Avoid placing the elevator along the lingual surface of the mandibular deciduous teeth. Instead, only elevate along the mesial surface (front), labial surface (toward the lip), and distal surface (caudally) of the mandibular deciduous teeth, and buccally and distally around the maxillary deciduous canines. Examination of intraoral radiographs before extraction is important to confirm that the tooth about to be extracted is a primary tooth (

Normally, deciduous canines exfoliate by 6 months of age. Occasionally, the crowns fracture secondary to chewing on hard objects. Waiting to extract a fractured deciduous tooth can lead to periapical infections and discomfort (

Discolored teeth are considered nonvital. Discoloration commonly occurs secondary to concussive or thermal trauma that results in internal bleeding and pulpal necrosis. Dull pain is reported by humans from pulpitis in discolored teeth. The treatment of choice for discolored teeth in dogs and cats is either root canal therapy to remove the nonvital pulp or extraction (

Once the pulp is exposed via fracture, oral bacteria infect the area, causing inflammation and pain. If left untreated, the pulp eventually will necrose, leaving an open portal for bacteria to populate the periapical tissues and cause pain. When diagnosed early and treated within 48 hours of the fracture, the tooth may be saved through vital pulp therapy. After 48 hours in the mature dog or cat, either root canal therapy or extraction is the treatment of choice.

When an adult maxillary cheek tooth is fractured with pulp exposure, the area below the eye often swells. When this occurs, administering antibiotics and anti-inflammatories usually results in temporary resolution. Within days to weeks, however, the swelling returns because it is secondary to complicated cheek teeth fractures with open pulp chambers. Successful treatment in these cases involves root canal therapy or extraction of the fractured tooth (

Once plaque and tartar result in gingival inflammation, it is time for professional dental scaling, irrigation, and polishing under general anesthesia. Treatment in these cases should not wait until the annual dental exam.

Tooth resorption that is exposed into the oral cavity

We still do not know the cause of external tooth resorption in dogs and cats, but we do know that once the resorption is exposed to the oral cavity, bacteria invades the pulp and causes inflammation and pain. Waiting, antibiotics, and anti-inflammatory medication are not indicated. Extraction is the treatment of choice.

The etiology of gingivostomatitis is believed to be multifactorial. This creates a challenge for any successful treatment other than full-mouth or selective extractions. In rare mild cases, stringent plaque control and a change in diet may be curative. Treating with repositol steroids or anti-microbials is wishful thinking with only short-lived improvement. In cases of refractory stomatitis despite extractions, CO2 laser ablation, with or without every-other-day oral prednisolone administration, shows promise in relieving inflammation (

Thanks to wellness plans that include dental evaluation, scaling, polishing, and full-mouth intraoral imaging, fees for needed dental care are less of an issue than they once were. Clients who understand the ramifications of dental disease and believe their dog or cat needs dental care will find a way to afford it. In-clinic and third-party payment plans are an option for most clients, and many pet insurance plans cover dental diseases as long as the pet was covered before the diagnosis was made.

Some clients are hesitant to proceed with recommendations because they fear general anesthesia will harm their pet. Thanks to Fear Free preanesthetic patient evaluation geared to the individual patient’s age and condition, patient-tailored preanesthetic and induction medication regimens, and close anesthesia monitoring during and after the procedure, anesthesia is considered safe with only rare adverse events.

Waiting in most of the cases outlined here is not wise and can lead to harm. When the moment of truth occurs during an oral exam, it is wise to be proactive in advocating for your patient. Your patient and client will thank you.

Dr. Jan Bellows owns All Pets Dental in Weston, Florida. He is a diplomate of the American Veterinary Dental College and the American Board of Veterinary Practitioners. He can be reached at dentalvet@aol.com.

When it comes to dental care, sometimes immediate action is a must for your patient’s health and comfort.

The ABCs of veterinary dentistry: When waiting is wishful thinking

Ambrose Animal Hospital has grown significantly over the past 12 years. What was 2 doctors and a staff of 11 is now 6 doctors and a staff of 45. Ambrose achieved this growth by practicing progressive medicine, hiring only top-quality staff, and being culturally sensitive. Ambrose believed staff diversity led to greater sense of community and tolerance among team members. Diverse races and sexual orientations were well represented among the hospital staff.

In the midst of the coronavirus disease 2019 pandemic, some of the clinic’s vendors started sending lunch for the front line veterinary workers. Curbside policies prevented the public from entering the hospital, and the staff was discouraged from going to restaurants on their lunch break. Having lunch sent in as well as the newly social distanced break room were much appreciated.

Not long after the lunch spreads started to be delivered, some staff members asked to speak with Ambrose. They explained to the owner that 2 of the restaurants that provided staff lunches advocated distasteful and objectionable policies. One espoused religious beliefs that resulted in homophobic statements, and the other displayed its pride in big game hunting via displays in their restaurants. The staff felt that their diverse workforce should not have to be exposed to services provided by a homophobic company, and a restaurant chain that advocates the killing of non-endangered big game was not consistent with the mission of the veterinary hospital. Ambrose thanked them for their input and verified that the information about the companies was correct.

As the practice owner, Ambrose was not comfortable patronizing any business whose policies offended or demeaned his clinic staff members. He proceeded to write a staff memo outlining his reasons for prohibiting staff from patronizing these restaurants during work hours. He was quite surprised when his memo was not as well received as he had expected.

Several staff members said that although they not approve of the restaurants’ policies, they did not feel their employer should be able to dictate their choice of restaurants. One noted that 2 of the clinic’s staff members ate only kosher food. They always brought their own lunch and did not object to their coworkers’ choice of foods. Another commented that neither restaurant was doing anything illegal.

Ambrose thought these comments were, quite literally, food for thought. He understood why some of his staff thought he was taking a cancel culture stance toward these objectionable restaurants and respected them for sharing their thoughts. He explained that he would never ask his employees not to patronize a business during 

 hours, but that as the practice owner he had the “boss's prerogative” to make the choice he did. He found the restaurants to be morally offensive and in good conscience could not allow their products on his premises. He understood there would be some whispering behind his back but chose to stick to his credo “to thine own self be true.”

Do you agree with Dr. Ambrose? Would you have made the same choice he did? We would like to know.Email your thoughts to dvm360news@mmhgroup.com.

Most veterinarians would never turn away someone whose pet is in dire need of veterinary care based on the owner’s lifestyle choices. The animal, of course, is always an innocent victim. As repulsive as the pet owner may be, it is still our job to care for animals in need. Ambrose would never refuse to care for an animal presented by a person who owned what he considered a morally offensive establishment. On the other hand, every individual—veterinarian or not—must decide when and whether they are going to take a stand based on their own moral imperatives.

Ambrose felt that the only way he could tell these 2 restaurant owners that he disapproved of their advocacies was to not purchase their products. He did nothing illegal, he did nothing violent; he simply spoke up with his pocketbook. He was well within his rights as a practice owner to make this decision, but he also had to expect that some staff disapproval would be a price he had to pay for taking a moral stance. Bravo!

Marc Rosenberg, VMD, is director of Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios Rosenberg describes in his column are based on real-life events, the veterinary practices, doctors, and employees described are fictional.

Do practice owners have the right to tell employees what and where they can eat while they’re on the clock? 

Cancel culture at the veterinary clinic

This week on dvm360, we will be posting a wide variety of news content including:

A brand-new episode of The Vet Blast Podcast: On Episode 23, you’ll learn about workplace injuries and how to reduce your risk.

An article on the ABCs of veterinary dentistry and the importance of immediate action.

An article on why contract enforceability is so hard to predict.

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