The gold standard of veterinary oral health care (Proceedings)

Veterinary dentistry has evolved to the point that consumers now demand and expect the best oral health care possible for their pets. Through the efforts of the American Veterinary Dental Society, Academy of Veterinary Dentistry and The American Veterinary Dental College in conjunction with the American Veterinary Medical Association, Hill's Pet Nutrition and other industry leaders the public has been made aware of the significance of our pet's oral health problems Industry has discovered the veterinary dental market and a plethora of companies provide all sorts of products designed to "freshen breath" and "reduce gum disease." Pets are living longer due to better nutrition and health care. Most veterinarians recognize the need for examining the pet's mouth as well as the rest of the patient's body to determine areas of medical concern. While the recognition of importance has improved, the delivery of care has not improved. It is time the veterinary health community elevate the care provided to satisfy consumer demand.

The Gold Standard of Veterinary Oral health Care includes:

• Thorough physical exam and history

• Preoperative blood profiles including blood gases

• Inhalation anesthesia with Sevoflurane

• Regional and local nerve blocks

• Concurrent IV fluid therapy

• Blood pressure, EKG, pulse ox, respiratory, body temperature monitors

• Intraoral dental radiology

• Air driven high speed dental equipment and complete hand instrumentation

• Trained dental operator

• Complete dental charting

• Home care.

• Rechecks

The Gold Standard of Veterinary Oral Health Care encompasses clinical pathology, anesthesiology, radiology, operative dentistry, oral medicine, and home care. The delivery system of oral health care must be as sophisticated as any other operative procedure in a small animal hospital. The dental prophylaxis is the cornerstone of operative dentistry and is technically more sophisticated than an ovariohysterectomy. Unfortunately too many times the oral procedure is delegated to an under trained and ill equipped veterinary technician whose sole responsibility is to perform as many "dentals" as possible in a day to increase practice revenues. This must stop.

Anesthesia and Preoperative Work Up

Oral procedures require general anesthesia. Hand scaling a patient's mouth while awake does not constitute a professional dental prophylaxis but rather is much like tooth brushing. It does remove some supraginigval plaque and calculus but is totally ineffective for subgingival pathology and is very limited in the number of teeth treatable. The reason pet clients request and some veterinarians provide this inadequate procedure is the fear of anesthesia. This should no longer be an issue.

Pets requiring anesthesia should receive a thorough physical exam and workup. The minimum database for any age patient is a CBC and blood gas study (such as Heska's IStat 8). Anesthesia alters physiology and the best assessment is evaluation of parameters affected by metabolism. Blood pH and bicarbonate levels are the single most critical tools for measuring the status of the patient. See figure 1. While the classic superchem profile gives some insight into the status of the patient it does not relate to acid/base balance and the hidden dangers of altering CO2 and O2 levels. The biggest trap veterinarians fall into is the patient with compensated metabolic acidosis or alkalosis. By adjusting the type of fluids given during anesthesia these dangers can be avoided. In addition, blood gas analyzers such as the IStat 8 gives insight into renal function, electrolyte levels and hemoglobin levels. In addition to the minimum database such tools as urinalysis, superchem profiles, cardiac ultrasound (in patients with heart murmurs or arrhythmias) add to the confidence levels of having a good outcome from the procedure.

Figure 1

All anesthetized patients receive IV fluids and are monitored for blood pressure, ekg, pulse oximetry, respirations, and body temperature. In addition, CO2 monitors or other similar devices are used. It makes little sense to reserve this equipment for patients in the operating room and exclude patients in the dental operatory. In general, IV fluids are delivered at a minimum rate of 1.5X maintenance (unless cardiac function is severely compromised). If blood pressure falls below a Mean Arteriole Pressure of 60 the fluid rate is increased and anesthesia reduced. Monitoring blood pressure is critical for renal function. Any patient emergency clinic will attest to the problem of acute renal failure in the post op "dental" patient that crashes several days after its procedure.

Preoperative agents include acepromazine for the young and restless and butorphenol for all. Anesthesia induction can be accomplished with mask induction for most all patients if Sevoflurane is the agent. It is non irritating to mucous membranes and even felines rarely object to induction. In fact, felines do well wrapped in a towel with a face mask. If the canine is unruly propofol works well to take the edge off and continue mask induction of any size dog. Drugs like ketamine or xylazine are not used nor needed. The best features of Sevoflurane are the rapid induction, rapid recovery and stable blood pressure through a wide range of vapor settings.

In addition to general anesthesia regional and local nerve blocks are used to minimize the need for general anesthesia and provide pain free recovery. These are easily accomplished using 25ga 1½ inch needles and bupivacaine or lidocaine. The mandibular nerve can be approached both intraorally and extraorally. The palatine and infraorbital nerve can both be reached dorsal to the distal edge of the hard palate. In addition, local blocks can be used if a single tooth is extracted and significant oral pain is anticipated. Both regional and local nerve blocks can be performed by licensed veterinary technicians following induction of general anesthesia and is part of routine protocols.

Radiology

Critical to veterinary dentistry and oral surgery is radiology. Veterinary surgeons would not consider operating on a fractured bone or open an abdomen without preoperative x-rays. The same is true for operating in the oral cavity. Failure to radiograph an area prior to extraction, oral biopsy or other invasive procedure is malpractice. Intraoral dental radiology is essential and critical to practice The Gold Standard.

Radiology in the past has been the use of conventional extraoral plates, placing the patient in lateral recumbency and radiographing the head. Superimposition is the biggest problem along with minimal detail of the radiographed area. The trained veterinarian may be able to identify the lesion but the casual observer will miss it. The author affectionately refers to these films as "brain shots."

Dedicated intraoral dental x-ray machine are affordable and versatile. They can be mounted on a wall or moved on a wheeled stand. They require simple 120v current and are virtually indestructible. They will be used every day and pay for themselves in a manner of months. Can the same be said of a "laser" surgery unit?

Intraoral dental films are high detail films that offer great insight into any oral pathology. The problems of superimposition are eliminated and with simple magnification oral pathology becomes easily identified. Apical granulomas, bone lysis, oral and nasal neoplastic lesions, dentigerous cysts, and feline resorptive lesions are a few of the lesions defined. Traumatic or pathologic fractures of the maxilla and mandible are correctly managed by determining the preexisting periodontic and endodontic status of the dentition. The nature of the fractures and complicating conditions such as root and alveolar fractures that will alter the healing process are identified and treated appropriately. Radiology is critical when endodontic therapy is performed. It is considered malpractice to fail to perform radiology when performing endodontics.

Intraoral radiology has now entered the digital age making the procedure even easier to perform. Digital radiology is faster than conventional intraoral films and provides better quality images. Software programs allow for manipulation of the image increasing diagnostic capabilities. In addition, the images are stored "on the hard drive" making retrieval much easier than fumbling through file cabinets. An additional feature is the ability to email the image to a specialist for a consultation. In fact, digital systems are now available, such as the Scan X Pro, that take from size 0 intraoral up to 10x12 images. This eliminates processors, x-ray film, smell and hassle. These images can be manipulated with software programs, such as Tigerview, that make interpretation a much easier task. And they can be emailed to specialists for consultation.

If any oral cavity therapy is provide, even the "dental", failure to provide diagnostic radiography is unacceptable.

Periodontics

Terms:

• Dental – obsolete term

• Conventional dental prophylaxis – to prevent and not altering tissue or structure in animal with minimal if any disease.

• Periodontal therapy – treatment of periodontal disease with closed curettage and scaling of areas of attachment loss.

• Surgical periodontal therapy – altering tissue that includes extractions, open curettage, and surgical repositioning of tissue for the treatment of periodontal disease.

Once the correct diagnosis has been made, the next step in the Gold Standard is to correctly treat the condition. Most veterinary practices employee technicians to perform the dental prophylaxis (the "dental"). This should be limited to conventional dental prophylaxis. If the technician is properly trained this is a good system. The technician should remove the gross calculus, radiograph the dentition, perform the nerve blocks if necessary, and step back for the veterinarian to perform periodontal therapy or surgical periodontal therapy as dictated by radiographic and probing findings. Periodontal therapy involves closed supraginigval and subgingival cleaning. Probing, defining areas of attachment loss, open and closed curettage are all part of the treatment. If these steps are not properly performed the periodontal problems will persist and in reality the disease will last longer than if the teeth were ignored and allowed to be naturally exfoliated. If the teeth are to be treated, it needs to be done properly, or not at all. If the pet does not require surgical intervention the technician should finish the prophylaxis and waken the patient.

Critical in this arena is instrumentation. The minimum instrumentation in The Gold Standard includes:

• dedicated area for oral procedures, preferably a dental operatory

• air driven equipment with high speed and low speed hand pieces

• ultrasonic, piezoelectric, or subsonic scalers (avoid rotary instrument)

• hand instrumentation including explorers, curettes, and scalers

• periosteal elevators and dental elevators

• surgical length and standard length burs

• prophy angles

• dental mirrors

• protective eyewear, masks, and gloves

Without this minimum equipment it is impossible to perform a thorough dental prophylaxis.

Dental charting is mandatory when performing dental therapy. Charting is a record of preexisting pathology (ie missing teeth) and therapies performed. Grading and staging diseases is a means to monitor success or failures of treatments. The author uses a I to VI grading system. (see figure 2). Regardless of the system used it is imperative that the records be consistent. Attachment levels, fractured teeth, extractions, oral masses etc are all noted on the record. If a copy of the chart is given to the client with an explanation of the notes, the client will realize the efforts put forth in caring for their patient. If the client is not given this information their understanding of the pet's problem is distorted and follow up care is difficult to attain. The more complete the dental chart, the more the clients realize the care provided by the professional. Finally, intraoral digital photography is an excellent method of recording pathology. Not only can these images be presented to the pet client, they can be forwarded to a specialist for consultation if needed. The previous record keeping entry of "dental, extractions, Rx amoxicillin 250 mg q12h x 7" is no longer acceptable.

Figure 2

Home care is important but must be realistic. While tooth brushing is ideal, most clients are dismal failures. However, products such as T/D diet, Science Diet Oral Care, and Friskies Dental Diet for cats actually work for plaque. Iam's product with "DDS" (hexamethylphosphate) and IVD Dental Diet also help for calculus control. Together, these products do a pretty decent job minimizing plaque and calculus reoccurrence. For those clients motivated and patients that tolerate tooth brushing, products with hydrogen peroxide as the active ingredient are helpful. Glyoxide (available over the counter) is a good choice due to its ease of applications and tolerance by the patients. Products containing hydrogen peroxide as the active ingredient are generally regarded as safe. Products containing chlorhexidiene are fine when used short term but should be used cautiously long term unless the patient learns to rinse and spit. Industry has provided a plethora of gadgets and devices which can be tried on an individual basis. The Veterinary Oral Health Council was established to certify efficacy of various dental diets and devices (www.vohc.org). Products with the VOHC seal actually perform as represented by the manufacturer.

The bottom line is that maintaining the oral cavity is the pet owner's responsibility. Any and all programs that encourage client participation are encouraged.

Rechecks

Rechecks are critical and an integral part of THE GOLD STANDARD. Unacceptable recommendations and observations to the client include: "the oral cavity doesn't seem bad today," "it doesn't appear to be causing the pet problems," "lets watch it." Companion animals will benefit from annual dental "prophy's". This allows the veterinarian to provide a thorough oral exam on a regular basis. Recognition of endodontic disease, and especially oral neoplasia, will be early. If the practice is not equipped to handle these problems referral to the appropriate specialist is offered. The failure to diagnose and refer is a major reason for client dissatisfaction and loss.

In conclusion, The Gold Standard is an attainable goal for all veterinary practices that provide oral health care. If the practice chooses to improve their delivery system the changes will be rewarding. The pet will be healthier and the clients happier. Everyone wins.

References

Companion Animal Dental Scaling Without Anesthesia. American Veterinary Dental College Position Statement adopted by the AVDC Board of Directors, April 10, 2004 www.avdc.org

Nelson RW, Couto CG, Essentials of Small Animal Internal Medicine, Mosby, St. louis, 1992, 205-206

Birchard SJ, Sherding RG, Saunders Manual of Small Animal Practice, 2nd Edition, WB Saunders Co, Philadephia, 2000, 78, 591, 918, 922.

Merck Veterinary Manual, Seventh Edition, Merck & Co, Rahway, NJ, 1361-1365.

Birchard SJ, Sherding RG, Saunders Manual of Small Animal Practice, 2nd Edition, WB Saunders Co, Philadelphia, 2000, 18-20

Regional Anesthesia for Dentistry and Oral Surgery, G Lantz, JVD Vol 20#3, 181-186.

Mulligan T, Aller MS, Williams CA, Atlas of Canine and Feline Dental Radiography, Trenton, Veterinary Learning Systems, 1998

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Wiggs RB, Lobrise HB, Veterinary Dentistry Principles and Practice, Lippincott-Raven, Philadelphia, 1997, 186- 231

Holmstrom SE, Frost-Fitch, Eisner ER Veterinary Dental Techniques for the Small Animal Practitioner, 3rd Edition, Saunders, Philadelphia 2004.

Bellows J, Small Animal Dental Equipment, Materials and Techniques, 1st Edition, Blackwell, Ames, 2004.

Comparison of the Effects of Four Different Power Scalers on Enamel Tooth Surface in the Dog, Brine EJ, Marretta SM, Pijanowski GJ, Siegel AM, JVD, 200 Mar 17(1) 17-21