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Saying you're sorry may go against everything you've been taught as a confident veterinarian, but being honest is the best option

Veterinary medical errors: Tell the truth, do it quickly

I read with interest Dr. Barry Kipperman's article, "Specialists and general practitioners share limitations." How very true that is! This seems to be a hot topic because your April issue had two articles about specialists versus general practitioners.

Sharing limitations

A recent study of koalas affected by bushfires in Australia revealed severe burns to footpads that hindered their ability to climb trees and to escape the dangerous conditions. Lung damage and generalized burns to the skin and furred regions were also found in these marsupials.

, the study was supported by a $54757 grant from the Morris Animal Foundation based in Denver, Colorado. The investigation relied on clinical data from koalas affected by catastrophic bushfires that occurred in the Australian summer of 2019-2020. Data collected included comprehensive health assessments of koalas, sample analysis, statistical analysis and extensive collaboration with wildlife rescue groups and veterinarians.

The histopathological features and the depth of burns in koala skin, and smoke-induced respiratory tract damage were studied. In 4 koalas affected by bushfires that were euthanized, burns to skin in various body regions were scored based on clinical appearance as superficial, partial thickness, or full thickness. Furred regions on the ear margins and dorsum were histologically more severe than other body regions. However, the study’s results found the most commonly burned body region was the plantar footpads in the hind legs, which investigators theorized was likely because of the koalas’ descent from trees to scorched ground. Investigators also found that pulmonary oedema and congestion were evident in the respiratory tracts of all studied koalas.

Investigators concluded that understanding of the injuries incurred by the studied koalas can be used to better assess the likelihood of survival, rehabilitation and release for these marsupials. “Compounding the effect of burns on the health of the koalas, a high likelihood of lung damage due to smoke inhalation has also been found by this study, and this is an important additional consideration for veterinarians triaging rescued koalas,” said Natasha Speight, a senior lecturer at the University of Adelaide, School of Animal and Veterinary Sciences, who led the study, in a news release.

Investigator noted that, overall, the study results demonstrate that cutaneous burn lesions on furred and footpad surfaces can have higher severity based on the burn depth than is clinically apparent. Therefore, they noted in the publication, there is a need to consider burn depth when developing treatment plans and establishing prognosis at triage for koalas that have been burned, as well as the high likelihood of pulmonary oedema exists, they wrote.

The study’s findings provide critical information that will improve koala care during future fire seasons. The study results also significantly advance understanding of the impacts of bushfires on wildlife, which is crucial for future planning and care coordination, according to investigators. “These resources can then be used by the government, wildlife carers and veterinarians to assess the prognosis for koalas that have injuries due to bushfires, as well as aid coordination of bushfire response efforts,” Speight said, in the release.

Publication identifies risk factors in koalas. News release. Morris Animal Foundation. January 9, 2023. Accessed January 9, 2023. 

https://www.morrisanimalfoundation.org/article/publication-identifies-risk-factors-koalas

Baek C, Woolford L, Funnell, et al. Cutaneous and respiratory lesions in bushfire-affected koalas. 

. 2023;10(11):658. doi:10.3390/vetsci10110658

The investigators’ findings may prove critical to improving care for wildlife affected by future fires

Clinical

Study analyzes severity of injuries in koalas affected by Australian bushfire

You know the importance of full mouth dental radiographs for your patients. However, the time it takes to get a diagnostic full mouth study is making you second guess this step.

If you want to ensure all patients get full mouth dental radiographs in a reasonable timeframe, and the bisecting angle technique makes you anxious, this article is for you. The subtle changes to the bisecting angle technique that will feel like “cheater codes” as well as this author’s approach to “bad radiographs” will be addressed.

These 2 things will help you and your team get consistently better radiographs faster. However, before we get to the “cheater codes” and “bad radiographs” we will start with a general overview of the 2 main intraoral dental radiology techniques: Intraoral Parallel Technique (IPT) and Bisecting Angle Technique (BAT).

The IPT is the same technique used to acquire diagnostic images for the rest of the body. The plate or sensor—

 will be used for both throughout the article—used to capture the image is positioned parallel to the target anatomy. The generator, also called the tube head, is positioned perpendicular to both the sensor and the patient.

The IPT is preferred as it allows for the most accurate image of the target anatomy with minimal distortion.

 If we could use this method for full mouth dental radiographs in our canine and feline patients it would be ideal. However, because of the absence of a vaulted palate and the presence of a mandibular symphysis, the sensor can only be placed parallel to the entire tooth for the mandibular molars and, in some patients, the most caudal mandibular premolars.

The anatomic differences between humans and veterinary patients means that the majority of our patient’steeth will require the BAT to obtain radiographs. The BAT is most commonly used in patients’mouths where the IPT cannot be used. However, it can be used for all teeth in patients’ mouths.

This is because the BAT is based on a geometric theorem: Cieszynski rule of isometry (

). This theory, coming from the geometric Law of Isometry, is applied to dental radiographs to obtain an accurate image when IPT cannot be used. The law has also been called the theory of equilateral triangles

, stating two triangles are equal if they have 2 equal angles and a shared side.

The reason for all this geometry is to ensure the image captured has the least amount of distortion. The other way to consider this is that BAT is a way to create an IPT when the sensor cannot be placed parallel to the entire tooth. Remember, the IPT has the tubehead directed perpendicular to BOTH the tooth and the sensor, which is not possible for most of our patient’s teeth. By bisecting the angle between the sensor and the tooth, this creates the angle to which the tubehead can be placed perpendicularly,similar to the IPT. While the BAT works for all teeth, the canine teeth given their curvature present a challenge. This article will first focus on the approach for imaging the majority of teeth and then will review the slight changes needed for imaging canine teeth.

Now that both intraoral dental radiography techniques have been reviewed, we can progress to the “cheater codes” to help improve your technique and speed.

The first way to simplify the BAT is to simplify the angles involved. Although many authors

 advise to place the sensor “as parallel as possible” to the tooth, it is this author’s recommendation and others

 that the sensor be placed perpendicular to the tooth. This small change in sensor positioning allows for a 90-degree angle between the tooth and sensor which is visually much simpler to bisect: 45 degrees. (

To ensure the sensor is perpendicular to the long axis of the maxillary teeth, the sensor should be placed parallel to the hard palate. For the mandibular teeth: using the patient’s tongue to fill the intermandibular space will give your sensor a flat surface to lay against that is perpendicular to the tooth roots. (

Positioning your patients in dorsal recumbency allows you and your team to complete the entire Comprehensive Oral Health Assessment and Treatment (COHAT) , including full mouth dental radiographs, without moving the patient or disconnecting any monitoring equipment. With the patient in dorsal recumbency, rotate their head 45°. By rotating their head and using the above simplification the bisecting angle will now be a vertical line which results in the tubehead angle being 0° or horizontally positioned. (

Once you get the correct angle for the first radiograph in the quadrant, do not change the angle of the patient, sensor or the tubehead. The only change to be made is to the move the sensor and tubehead either mesial or distal along that quadrant. This will save time by not rechecking any of the angles.

The biggest challenge to the bisecting angle simplification are the canine teeth. This is because while the rest of our patient’s dentition have similar angles between the crowns and roots, the canine teeth do not. (

Instead of using the angle of the crown for the canine tooth, the angle of the rostral mandible should be used. This is because the root of the canine tooth follows that curvature. (

) Canine teeth are a bit of an anatomical exception, given their crowns and roots do not have the same angle, you need to use the root angle to get the correct bisecting angle. 

Often a nondiagnostic radiograph, missing part of the tooth or inappropriate angle, is called 

. The radiograph is only bad if you do not then use it to help you get the diagnostic radiographs you want.

In this author's experience teaching dental radiography, most participants are quick to be critical of nondiagnostic radiographs. They often change patient, sensor and tubehead positioning or angle all at once. 

Instead, it is important to focus on the positives of the nondiagnostic radiograph, to determine what should not be changed. The main 2 things to focus on are whether the angle is correct and whether the teeth of interest are in the radiograph in their entirety. 

is a nondiagnostic image. It is nondiagnostic because the apex of the roots are not included in the image, however, the angle of the image is correct. Therefore, the only change that should be made is a sensor movement.

Once the sensor was moved further into the mouth, in a palatal direction, the entire root structure of right maxillary molars (109/110) are included in the image as well as the distal root of the maxillary fourth premolar (108). (

) The part of the sensor that could be seen outside of the mouth or beyond the teeth in image (a) corresponds to the black space in the dental radiograph in previous figure. It is important to line up the long side of the sensor with the cusp of the tooth/teeth to ensure the entire senor is used. This sensor placement is similar to collimating full body radiographs: ensuring 

 the target anatomy is within the radiograph.

Other times a “bad” radiograph may be caused by angles and not sensor placement. In those instances, the angle of the tube head may need to be corrected.

shows all the desired teeth are in the radiograph, however, the angle is very foreshortened, making this image nondiagnostic. Given that all desired teeth are included in the image, the sensor should 

be moved, instead the angle of the tube head should be corrected.

was very foreshortened, which fits with a small angle, almost parallel, between the tooth and the tube head. 

 shows a very large angle, almost perpendicular, between the tube head and the tooth, which resulted in the very elongated dental radiograph shown in 

, which demonstrates the second radiograph in the feline patient. Both tube head angles in the above figure failed to follow the angles outlines above for BAT.

To get the diagnostic image for this feline patient the tube head must be at an angle between that in Figure 11a and Figure 11b. 

 shows the correct angulation of the tube head and corresponding, diagnostic, dental radiograph (

). This feline 'patient' was placed in dorsal recumbency with the head titled at 45°, which resulted in a bisecting angle that is a vertical line and therefore the tube head angle should be horizontal. 

Evaluating the 'good' parts of your nondiagnostic dental radiographs will help you get to a diagnostic radiograph faster than focusing on what is 'bad' about it. This, other tips or 'cheater codes' will help decrease the time needed to take full mouth radiographs. As with any skill, this will take time and practice to learn this new way of obtaining and evaluating your dental radiographs.

, is a specialist in small animal dentistry and oral surgery. She began her career in small animal general practice and, although challenging at times, she gained a great deal of dentistry education. The more she learned, the more her passion for dentistry grew as well as a desire to become a specialist. While Thomson enjoys all aspects of clinical practice, she also very much enjoys providing continuing education for all veterinary professionals in small animal general practice. There is a huge demand for veterinary dentistry and oral care, and she wants to support general practice teams to provide the best care to their patients.

Altier B. Tips for mastering veterinary dental radiology. 

, January 19, 2021. Accessed February 27, 2025. 

https://www.dvm360.com/view/tips-for-mastering-veterinary-dental-radiography

Wigg’s Veterinary Dentistry: Principles and Practice. 2

Altier B. The ABCs of dental radiology: dental radiology demystified (Proceedings). 

. September 1, 2019. Accessed February 27, 2025. 

A veterinary dentistry expert shares tips for achieving full mouth images using 2 main techniques and 'cheater codes'

A.D. Elkins, DVM, MS, DACVS

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