The ABCs of veterinary dentistry: Q is for quality, not quantity
Jan Bellows, DVM, DAVDC, DABVP, FAVD
Has the flurry of dental appointments that accompanies Pet Dental Health Month compromised the careful dental care of our patients? Lets take a look at the true meaning of Q in veterinary dentistry.
In 1993, the president of the American Veterinary Dental Society, Ken Capron, DVM, FAVD, DAVDC, wanted to draw attention to the dental needs of dogs and cats. To raise awareness, Dr. Capron created Pet Dental Health Month, which takes place every February. Two years later, Hill's Pet Nutrition added much-needed national marketing, which continued for 25 years. With the help of Hill's, Robert Wiggs, DVM, DAVDC, spoke on national television in over 22 cities in the United States about National Pet Dental Health Month.
What initially began as a campaign for dental awareness, Pet Dental Health Month in some practices has morphed into discounted dentistry to bring clients and their pets into veterinary offices in the prime of winter. Some hospital administrators gauge the health of their practices based on how many “dentals” are performed in February. This is far from the original intention of Drs. Capron and Wiggs.
All of this to say-squeezing in numerous discounted dental cases where veterinary assistants remove plaque and calculus from the crowns of teeth without conducting a tooth-by-tooth evaluation, including probing and intraoral radiographs and treatment of all periodontal pockets, is the practice of quantity, not quality medicine.
Achieve quality with COPAT
The challenge is incorporating quality dentistry into everyday practice. How do you focus on quality over quantity of dental cases without harming the hospital's bottom line by doing fewer cases? Answer: By adopting COPAT-comprehensive oral prevention, assessment and treatment.
Prevention involves measures taken to prevent the development or progression of oral disease by means of routine oral examinations, professional dental cleanings, home oral hygiene, etc. The COPAT visit is not complete until you discuss with the client how to keep their pet's mouth clean and how to minimize recurrence of disease.
Assessment is the collection and analysis of data to identify the patient's needs and includes obtaining a patient history from the owner and performing a physical examination of the conscious patient, laboratory and other tests to determine patient health and anesthetic risks, and a tooth-by-tooth intraoral examination including diagnostic imaging while the patient is anesthetized.
Treatment is the oral care recommended and performed by a professional based on the findings from the anesthetized tooth-by-tooth and oral cavity examination. The client's input is important in order to tailor individual treatment plans based on the exam findings and the client's financial ability and willingness to provide home care for further prevention.
Executing the perfect setup
The COPAT appointment is made based on the veterinarian's recommendation during a general examination or when a client calls concerned with oral malodor. The receptionist booking the appointment should discuss the process-patient examination, preanesthetic testing, general anesthesia, tooth-by-tooth examination including probing and intraoral radiographs, dental scaling, polishing, treatment of pathology, sealant application, and prevention recommendations. Generally, drop-off appointments are not recommended for the initial conscious examination. It helps for the client to be present while the veterinarian initially examines the mouth.
The receptionist should also explain that further care recommendations will be discussed with the pet owner after the veterinarian examines the teeth and oral cavity while the dog or cat is anesthetized. If time is not available to treat discovered pathology, or if the client wishes to consider treatment options longer, the cat or dog should be recovered from anesthesia and a future appointment made to complete treatment.
Fees for the visit should be discussed by the receptionist when booking the appointment. Keep in mind, the receptionist cannot tell the pet owner what the final charges will be to care for the patient without the anesthetized diagnostic doctor examination. Expenses for what is known, such as preanesthetic examination, preanesthetic tests, anesthesia, monitoring, dental scaling, polishing, sealant application, and dental radiographs, can be quoted. The pet owner should be advised there will be additional fees to care for any potential pathology found, which would be discussed before additional therapy is provided (Figure 1).
Figure 1. A receptionist fielding questions and explaining the COPAT visit. (Photos courtesy of Dr. Jan Bellows)
Before the patient goes under …
Unless a recent examination has been conducted, the veterinarian usually performs a general physical examination with the client present. This exam typically includes as much of an oral assessment as the patient will allow. It's important that the examination be conducted in a fear- and pain-free manner. The extent of an examination on a nonsedated animal depends on patient cooperation and expertise of the examiner and assistant. Most dogs and cats will allow an initial evaluation of their teeth and oral cavity when approached in a slow, gentle manner. Some are too fractious to inspect without chemical restraint, which can be accomplished in the exam room setting or during general anesthesia. Periodontal probing should never be done in an awake patient.
The gingival margin lies next to the tooth coronal to the attached gingiva. Healthy gingiva appears light-pink. Gingival inflammation clinically presents as erythema and is often accompanied by rounding of the originally knife-edged gingival margins. As periodontal disease progresses, tooth roots may be exposed secondary to gingival recession.
Exam findings and the plan for the day are shared with the client together with a printed list of estimated fees for the assessment (preoperative blood/urine/heart/radiographic tests based on age and condition; dental probing; and intraoral radiographs), teeth cleaning, polishing and irrigation with sealant application. The client is given a time to return to the office to learn what additional care is needed or a callback time to discuss findings and the treatment plan after the tooth-by-tooth examination (Figure 2).
Figure 2. An assessment of a patient's teeth.
While the patient is under …
The patient is anesthetized and monitors attached. Teeth are scaled, crowns are polished, and the gingival sulcus is irrigated to remove plaque and calculus. Full-mouth radiographs are taken and prepared for the veterinarian to examine. The veterinarian or technician performs a tooth-by-tooth exam, noting missing, fractured or mobile teeth and periodontal pockets. All abnormal findings are charted, providing a graphic report of the pet's teeth and mouth in order to develop an accurate and comprehensive treatment plan (Figures 3 and 4).
Figure 3. A patient being preoxygenated before anesthesia.
Figure 4. Left maxillary cheek teeth radiographs revealing advanced periodontal disease affecting the third premolar and first molar teeth.
The dental top 10: Options for basic and advanced dental care
1. Future follow-up within six to 12 months after dental scaling in cases where pathology is found in a pain-free, functional mouth.
2. Dental scaling, irrigation, polishing and application of professional plaque barrier gel or sealant in cases of stage 1 gingivitis (inflamed gingiva without evidence of support loss) and stage 2 nonpocket periodontal disease (< 25 percent support loss) as evidenced by gingival recession.
3. Local antimicrobial administration: Clindoral (Trilogic Pharma) and Doxirobe (Zoetis) may be helpful in periodontal disease stage 1 bleeding on probing areas, stage 2 and stage 3 (25 to 50 percent support loss) where there are periodontal pockets from which plaque and calculus have been removed and where the pet owners can provide home care to control periodontal disease progression. Locally applied antimicrobials are not indicated in deep infrabony pockets and should not be administered without first taking and examining intraoral radiographs.
4. Periodontal surgery to save teeth if the tooth and patient are appropriate. Operculectomy (removal of the gingiva over an unerupted tooth crown) is indicated in a young dog or cat (less than 8 months old) where the tooth is expected to fully erupt in normal alignment once the obstructing gingiva is excised. Open-flap surgery for cleaning and débridement is used to expose a tooth root in selective cases where the periodontal pocket extends greater than 5 mm and the client is committed to providing home care to save the pet's teeth despite a guarded prognosis. Gingivectomy can be performed to remove pseudopockets in cases of focal or generalized gingival enlargement.
5. Vital pulp therapy is performed to treat a recent (less than 48 hours) crown traumatic fracture that has penetrated dentin exposing the pulp. Vital pulp therapy and crown restoration can also be performed after reduction of crown height for the treatment of tooth malposition causing gingival trauma.
6. Root canal therapy is often the treatment of choice for end-stage pulp disease secondary to fracture, chronic pulpitis or caries. Therapy planning must consider the age of the animal, duration of pulp exposure, importance and condition of the tooth and periapical structures.
7. Crown reduction with gingival closure can be used to treat type 2 root resorption. Crown reduction and restoration can also be used to alleviate a traumatic occlusion.
8. Orthodontic care can reposition teeth into functional occlusion. An inclined plane fabricated from acrylic composite or metal can move linguoverted mandibular canines, and orthodontic buttons can be cemented on teeth affixed with elastics to move malpositioned teeth into functional nonpainful positions.
9. Oral surgery is usually the treatment of choice to care for oral masses, both benign and malignant. When considering oral surgery, generally a 1-cm margin is indicated for benign masses and 2-cm or greater margins for malignant tumors.
10. Extraction is the chosen therapy to treat moderate and advanced periodontal disease, fractured teeth with pulp exposure when root canal therapy is not an option, tooth resorption exposed to the oral cavity, and penetrating malpositioned teeth.
Don't forget this while the patient is out
Once the tooth-by-tooth therapy plan is generated, contact the client to discuss and gain approval. In cases where time doesn't permit treatment after dental scaling and diagnostics, appointments are made for future care (Figure 5).
Figure 5. A veterinarian discussing exam findings and gaining approval for needed therapy.
Before you go … thoughts after surgery
At the completion of surgery, postoperative intraoral radiographs are taken and examined for remaining dental hard tissue. The patient is recovered with continuous monitoring. (Note: Most adverse anesthesia events occur during the postoperative period). After the patient fully recovers, the dental chart is completed and a report is generated to review with the client (Figures 6-10).
Figure 6. Completion of oral surgery.
Figure 7. Postoperative intraoral radiographs of the left caudal cheek teeth confirming complete removal of all hard dental tissue.
Figure 8. Recovery monitoring, including assessment of pulse oximetry and elevated heart rate.
Figure 9. A veterinary assistant preparing the pictorial report.
Figure 10. Review of the COPAT visit with the client.
Dental home care highlights for clients
One of the challenges in veterinary dentistry is diminishing the accumulation of plaque and calculus after the COPAT visit. Before periodontal treatment is initiated, talk with pet owners about their commitment and ability to provide aftercare. There is little reason to perform intermediate or advanced periodontal surgical procedures if the pet owner will not, or cannot, actively participate in ongoing plaque control. If there is little to no commitment to home care and follow-up examinations, it's better for the veterinarian to extract teeth affected with stage 3 or 4 periodontal disease.
After the professional oral hygiene visit, schedule weekly progress examinations until the owner is comfortable with the home care process. Thereafter, recheck advanced periodontal surgical cases every two to three weeks and, eventually, less frequently. Pets that have been treated for stage 1 or stage 2 periodontal disease and whose teeth are brushed or wiped once or twice daily can be reexamined every three months. The automatic reminder interval for recalls can be linked by the practice's software to the degree of periodontal disease (i.e. if the patient is treated for stage 3 periodontal disease, a monthly progress reminder can be automatically generated).
The sweet spot: Quality and quantity
Quality dentistry takes more time to deliver than quantity dentistry. But with at least 80 percent of adult dogs and 70 percent of cats nationwide suffering from periodontal disease, there is a lot of quality dentistry that needs to be delivered. Invest the time and resources to find the cause of your patient's halitosis. As a result, the proper therapy will generally be approved and charged accordingly. Charge what you need to keep the patient and hospital healthy.