The Appointment Phone Call

When the client calls to schedule an oral assessment, treatment, and prevention visit for his or her pet, the positive final outcome is in some measure dependent upon how the appointment is made.

 The words "prophy," "prophylaxis," and "dental" are often misused in veterinary medicine. A dental prophylaxis is performed on a patient with an essentially healthy mouth, or with mild gingivitis, to prevent periodontitis. Patients with existing disease undergo dental treatment, not prophylaxis.

 It is impossible to render an accurate quote for the entire dental procedure until the patient's teeth and oral structures are examined under general anesthesia with x-rays. Once a full examination has been performed, the doctor can call the client with exam findings, proposed treatment, fees, and an estimated time for patient release.

 Fee quotes can be given for those procedures to be performed before the tooth-by-tooth exam such as patient examination, preoperative testing, initial anesthesia, monitoring, intravenous fluids, radiographs, teeth cleaning and polishing.

 The receptionist should provide recommendations concerning withholding food and water before the procedure.

Time-Line From Intake Exam to Exit Interview

9:00 - The Patient Intake Exam (First Patient - Others Follow in Turn)

Oral/Dental Examination in the Conscious Patient

Record all findings in the patient's medical record [Table 6]. Evaluate the head and oral cavity visually and by palpation. Abnormal signs to look for include pain; halitosis; drooling; dysphagia; asymmetric, discolored, fractured or mobile teeth; inflammation and bleeding; and changes in the range of motion or signs of pain in the temporomandibular joint. Areas to evaluate include the eyes; lymph nodes; nose; lips; teeth; mucous membranes; gingiva; vestibule (i.e., area between gum tissue and cheeks); palatal and lingual surfaces of the mouth; dorsal and ventral aspects of the tongue; tonsils; and salivary ducts. Note all abnormalities such as oral tumors, ulcers or wounds.

The oral examination on an awake patient allows the practitioner to design a preliminary treatment plan. Only when the patient has been anesthetized can a complete and thorough oral examination and precise treatment plan be formulated.

Assessment by Life Stage

Focus on age-related dental conditions and common abnormalities in the dog and cat. From birth to 9 months of age, evaluate the patient for problems related to the deciduous teeth, missing or extra teeth, swellings and oral development. From 5 months through 2 years, evaluate patient for problems related to developmental anomalies, permanent dentition, and the accumulation of plaque and calculus. Periodontal disease may begin at this time, especially in small breed dogs and cats. The onset and severity of periodontal disease varies widely with breed, diet, and home care. In small-breed dogs without home care, periodontal disease can start as early as 9 months of age. In large-breed dogs it may not start until years later. Most small dogs have periodontal disease by three years of age.^7-10 From 2 years of age and onward, evaluate the progression of periodontal disease, as well as the existence and adequacy of home dental care. Continue to evaluate for progressive periodontal disease and oral tumors in pets as they age.

9:30-10:30 Pre-operative Blood, Urine, Electrocardiograph Tests Performed and Reviewed

11:00-11:30 Pre-anesthetic Medication, Induction, Intubation, Anesthesia

11:30-12:30 Teeth Cleaning, Polishing, Intraoral Radiographs, Tooth-by-tooth Evaluation, Creation of an Estimate for Needed Dental Care

Dental procedures must be performed by a licensed veterinarian and/or a credentialed technician in accordance with state or provincial practice acts. During such procedures, use a consistent method of recording findings in the medical record [Table 6].

Positioning and safety of the patient is important. Manually stabilize the head and neck when forces are being applied in the mouth. Avoid using mouth gags, as they may cause myalgia, neuralgia, and/or trauma to the temporomandibular joint. If a mouth gag is necessary, do not fully open the mouth or overextend the temporomandibular joint. Disconnect the endotracheal tube when repositioning the patient to prevent trauma to the trachea.

Click on the chart to see a larger view

Teeth Cleaning

The essential steps for the oral assessment, treatment and prevention of periodontal disease are as follows:

1. Perform an oral evaluation as described for the conscious patient.

2. Radiograph the entire mouth using intraoral or digital radiographic systems. Standard views of the skull are inadequate when evaluating dental pathology. Take oral survey films at the initial examination and periodically thereafter. Take specific or localized radiographs when oral pathology is discovered.^1,4 Radiographs are necessary for accurate evaluation and diagnosis. In one published report, intraoral radiographs revealed clinically important pathology in 27.8% of dogs and 41.7% of cats when no abnormal findings were noted on the initial examination.¹⁶ In patients with abnormal findings present, additional pathology was revealed via radiography in 50% of dogs and 53.9% of cats.¹⁶

Click on the image to see a larger view

Digital intraoral survey images (additional films behind those visualized)

3. Scale the teeth using a hand scaler or powered device. Do not use a rotary scaler, which excessively roughens the tooth enamel.¹⁷

4. Polish the teeth using a low-speed hand piece with prophy paste that is measured and loaded on a prophy cup (for each patient, to avoid cross-contamination).

5. Perform subgingival irrigation to remove debris and polishing paste and to inspect the crowns and subgingival areas (for pathology).

Irrigation with air/water syringe

Irrigation with plastic syringe

6. Apply anti-plaque substances, such as fluoride and/or sealants. (final step after dental treatment)

Application of FluraFom® (Virbac) on gauze

Application of fluoride on cheek teeth

Removal of excess fluoride foam with dry gauze

Plaque Barrier Application Under Anesthesia

Teeth thoroughly dried
OraVetTM barrier sealant (Merial) applied with applicator gun supplied by the manufacturer	OraVetTM barrier sealant pressed subgingivally with gloved finger onto the teeth and into the sulcus and interdental spaces
OraVetTM barrier sealant may also be dispensed from applicator gun into prophy cup	OraVetTM barrier sealant spread on teeth, sulci, and interdental spaces

7. Evaluate for abnormal periodontal pocket depths using a periodontal probe. The depth that is considered abnormal varies among teeth and with the size of the dog or cat.^1,2,4

Periodontal probe before subgingival placement

7 mm periodontal pocket

Technician obtaining digital images of anesthetized patient for client report

Doctor reporting oral exam findings and gaining permission for therapy

Click on the chart to see a larger view

12:30 - To End of Procedure - Treatment for Pathology Found During Tooth-by-Tooth Exam Once Approved by Client

8. Perform periodontal therapy [Table 1] as determined by radiographs and probing.

9. Administer perioperative antibiotics when indicated, either parenterally (at time of catheter placement) or via local antimicrobial administration (LAA).^18,19 The purpose of prophylactic parenteral antibiotics is to treat bacteremia. The purpose of doxycycline locally administered is to block collagenase.

Periodontal pocket

Local antibiotic (doxirobe®) application

Water used to harden gel

Plastic Beaver Tail applicator used to pack gel

10. Perform periodontal surgery to remove deep debris, eliminate pockets, and/or extract teeth.

Periodontal/endodontal abscess	Extraction of the affected tooth
Periodontal and periapical luciencies, first molar

3:00 Technician Preparing Exit Case Report Images

Clinical image of dog presented with halitosis	Radiograph showing attachment loss

11. Biopsy all abnormal masses (visualized grossly or in radiographs) and submit samples for histopathology.

Fibrosarcoma caudal maxilla

Squamous oral carcinoma mandible

12. Obtain post-operative radiographs to evaluate the treatment applied.

Postoperative appearance

Postoperative radiograph of extraction sites

13. Recommend to the client that the pet be referred to a specialist when the practitioner does not have the skills, knowledge, equipment or facilities to perform a given procedure or treatment.

Discolored mandibular canine secondary to pulpitis

Palatal impingement of mandibular canine

Swelling due to infected root fragments

Swelling resolved following removal of root fragments

Post-operative Management

Maintain an open airway via intubation until the patient is swallowing and is in sternal recumbency. Maintain body temperature and continue intravenous fluid support as needed. Continuously monitor and record vital signs until the patient is awake. Continue pain management while the pet is in the hospital and upon discharge.^12,20

Recovery

5:00 Exit Interview

Post-operative Communication

Client communication is fundamental to ongoing dental care. At the time of discharge, discuss operative procedures and existing or potential complications (e.g., bleeding, coughing, dehiscence, infection, neurological signs, halitosis, vomiting, diarrhea, inappetence, and/or signs of pain). Discuss immediate post-operative home care, including medications and their side effects. Provide antibiotics and medication for inflammation and pain only as indicated.^18,19 Discuss any change in diet that might be necessary, such as a change to soft or premoistened food, or to a prescription diet. Provide individualized oral and written instructions at the time of discharge. Make an appointment for a follow-up exam and further discussion.

Doctor reviewing report with the client

Recheck Visit Two Weeks Later...

Progress or Follow-up Evaluations

With each follow-up examination and telephone communication, repeat the home care instructions and recommendations to the client. Set the number and timing of regular follow-up visits based on the disease severity. Although few studies have been performed in dogs and cats, extrapolation from the human literature and guidelines about aging in dogs and cats leads to the following recommendations.²¹

At a minimum, evaluate patients with a healthy mouth at least annually. Examinations every 6 months can help ensure optimal home care. Evaluate pets with gingivitis at least every 6 months and those with periodontitis at least every 3 to 6 months. Advanced periodontal disease requires monthly examinations until the disease is controlled. During subsequent examinations, evaluate client compliance, revise the treatment plan as needed, and redefine the prognosis.

Pets can live longer, healthier lives if oral health care is managed and maintained. All members of the veterinary team must strive to increase the quality of dental care delivered. Clients must be given options for the optimal care and treatment available for their pets. Dentistry is becoming more specialized, and referral to a specialist is recommended if the necessary expertise and equipment is unavailable at the regular veterinarian's office.

Teeth wiped dry with gauze

Applicator used to remove OraVetTM Plaque Prevention Gel (Merial) from the container

Application of OraVet Plaque Prevention Gel

Home Care

Home care is vital for disease control. Telephone the client the day after the procedure to inquire about the pet's condition, to determine the client's ability to implement the medication and home-care plan, and to answer questions or address the client's concerns. The home care plan includes the frequency, duration and method of rinsing and brushing; applying sealants, and the use of special foods (dental diets) and dental chews. Some of these details might best be left for discussion with the client at the first postoperative follow-up evaluation. Because the Veterinary Oral Health Council (VOHC; www.vohc.org) was formed to certify the efficacy of oral products, the dental team is encouraged to recommend VOHC-certified products.