priligy korea

Bookmark this article! [?]

BlinkbitsBlinkListsBlogLinesBlogmarksBuddymarksCiteULikeCo.mmentsDel.icio.usDiggDiigo

FarkFeed Me LinksFurlGoogleLinkagogoma.gnoliaMister WongNewsvinePropellerRawsugar

RedditRojoSimpySphinnSpurlSquidooStumbleUponTailrankTechnoratiYahoo

How to incorporate dental radiology into your practice

All small animal practitioners routinely take radiographs of patients where indicated. Radiographs simply put, help the veterinarian evaluate the patient.

Figure 1: Dental radiographic units allow for use on the operatory table.

In a study conducted at the University of California, Davis ( Am J Vet Res 1998, 59, pgs. 686-691 and 692-695), where all dogs and cats presented for dental cleanings were radiographed, significant lesions requiring therapy were uncovered in a majority of the cases. Currently, less than 10 percent of practices use dental radiology to help their patients. This low percentage is due to many factors including set up expense, inexperience with radiographic technique and processing as well as inexperience with film interpretation.

What are the advantages, equipment needed and techniques used to expose and process dental films?

Advantages of taking dental radiographs are many:

 

Figure 2: There are three film speeds: D, E, F.

The radiographic unit A conventional radiograph unit can expose quality films using 100 ma 10 mas technique at 40(cat)-60 (large dog) Kv, with a film focal distance of 16-in. While the veterinarian does not need to own a dedicated dental unit, it makes the process more efficient.

There are great advantages in owning a dental radiograph unit: most dental units cost between $3,000-$5,000; shorter film focal length and automatic collimation result in less scattered radiation and exposure to the patient; extension arms of various lengths allow vertical, horizontal, and rotational movement resulting in less patient repositioning; and radiographs can be obtained on the dental operatory table rather than moving the patient to a radiography area (Figure 1).

Figure 3: Dental film sizes

The film The efficiency which a film (Figure 2) responds to X-ray exposure is known as film sensitivity or speed. The three film speeds are:

 

Figure 4: EVA digital dental sensor and holster (AFP Imaging).

Exposure example for a typical 20-pound dog using a dental radiograph unit is 55kVp, 10 mA: Ultraspeed 0.40 sec, Ektaspeed 0.30 sec, InSight 0.16 sec.

Four sizes of dental film are used (Figure 3, p. 12S):

 

Figure 5: Positioning for incisor images.

Digital dental radiology uses a sensor rather than film. The image captured on the sensor is displayed on a computer screen. (Figure 4, p. 12S).

A radiographic dental survey consists of a minimum of eight views:

  • Rostral maxilla
  • Lateral left canine
  • Lateral right canine
  • Rostral mandible
  • Right maxillary cheek (premolars and molars) teeth.
  • Left maxillary cheek teeth
  • Right mandibular cheek teeth
  • Left mandibular cheek teeth

Tube/film/patient positioning For the maxillary views, the patient is positioned in sternal recumbency with support placed under the chin at a height where the muzzle is parallel to the tabletop:

 

Figure 7: Maxillary premolar tube position.

Determine the angle between the plane of the canine root and the plane of the film. Position the cone perpendicular to the bisected angle (Figure 6).

 

Figure 8: Maxillary molar tube and film position.

The maxillary fourth premolar has three roots (mesial buccal, mesial palatal and distal). To avoid overlap of the mesial buccal and palatal roots, position the PID 20-degrees in the horizontal plane (rostral oblique) in the medium- to long-muzzled dog, and caudal oblique in brachycephalic breeds. In cats, the zygomatic arch is superimposed over the maxillary fourth premolar root. To avoid the arch, use a rostral oblique bisecting angle projection, aimed at the premolar roots with the PID positioned just ventral to the arch. Alternatively, extraoral near-parallel technique may be used to visualize the maxillary cheek teeth (Figure 7).

 

Figure 9: Mandibular incisor position.

When radiographing the mandible, place the patient in ventral or lateral recumbency with support under the neck to place the muzzle parallel to the tabletop.

 

Figure 10: Mandibular canine tube and film position.

Film may be developed in the following ways:

Manually, using developer, water and fixer solutions in the practice darkroom.

Figure 11: Position of film and tube head to expose mandibular premolars.

With the chairside darkroom, a portable light-safe box containing rapid developer, distilled water and fixer in small containers is placed in the dental operatory. The chair- side darkroom is covered with a plexiglas safety filter, which enables operators to see their hands while handling the film(s). The filter is either amber (when D speed film is exposed), or red (for E or F speed films). Processing time from opening the film packet to initial examination of a rinsed film takes approximately two minutes (Figure 13).

Using an automatic dental processor (preferred by author) delivers dry films in six minutes.

Manual processing Manual processing includes the following steps:

Figure 12: Position of film and tube head for exposure of mandibular molars.

1. After exposure, carry the film into the practice darkroom or chairside darkroom for processing. Slide the film packet tab down to present film, cardboard and lead blocker. The film will feel firm to the touch, compared to the other film pack contents.

2. A film hanger is attached to the film edge. Touch only the sides of the film with fingers. Apply a gentle tug to make certain the film is firmly attached to the clip.

3. Place the film in prestirred developer solution for the specified time recommended by the manufacturer (Kodak Rapid Access Chemistry: 15 seconds at 68-degrees). Note: an alternative method starts manual film processing with water immersion to soften the emulsion before placement in the developer.

Figure 13: Manual chairside darkroom.

4. After placement in the developer, rinse the film in fresh distilled water (wash) for 10-15 seconds. Rinsing removes the alkaline developer from the film surface, preventing mixture with the acid fixer.

5. Place the film in the prestirred fixing solution for at least two minutes. Fixer removes the unexposed or underdeveloped silver halide crystals and rehardens the emulsion.

6. Rinse the film for 30 seconds in distilled water.

7. After viewing, place the film back in the fixer for five minutes, followed by distilled water rinse for 10 minutes.

Real world logistics

8. When rinsing is complete, attach the radiograph to a clip on the drying rack. Dental radiology is as important to patient dental care as radiology in any other organ system. The information gained is crucial to perform quality dentistry. The next article will concern evaluating dental films to help formulate a dental treatment plan.

By Dr. Jan Bellows

  • Incisors: Position the film packet toward the tube head against the incisors and the lingual frenulum. Position the PID perpendicular to the bisecting angle (Figure 9).
  • Canine: Place the patient in ventral recumbency. Position the film between the tongue and mandible, pushing the lingual frenulum distally. To obtain a lateral view, position the PID approximately 45° toward the canine (Figure 10).
  • Anterior premolars: Place the patient in lateral recumbency, with the film against the anterior premolars to include the periapical area. Aim the PID at the apex of the first premolar 20 degrees to the ventral border of the mandible (Figure 11).
  • Posterior premolars and molars: Place the patient in lateral recumbency. Position the film at the floor of the mouth lingual to the premolars. Place gauze or a hemostat to help depress the film into the floor of the mouth. Aim the PID perpendicular to the tooth roots and film (parallel technique) larger teeth, survey studies, and maxillary occlusal views in dogs and cats (Figure 12).
  • Molars: Place the film packet against the maxilla beneath the molar teeth. Aim the PID at the eye and film in a caudoventral direction (Figure 8).
  • Premolars: Place the film packet as close as possible to the inner surface of the cheek teeth. Aim the PID at the roots of the premolars at approximately 45-degrees.
  • Incisors: Place the film packet toward the tube head against the incisors and palate. Position the PID perpendicular to an angle bisecting the film and teeth planes (Figure 5).
  • Canine: Place the film packet facing the tube, between the tongue and maxilla beneath the canine tooth root. Center the PID over the mesial root of the second maxillary premolar, dorsally or laterally depending on the view needed.
  • Child periapical (size 0) measures 7¼8 x 15¼8 inches. Size 0 is used mostly in cats, exotics and small dogs.
  • Adult bitewing (size 2) measures 11¼4 x 15¼8 inches and is the most commonly used size in veterinary dentistry. Size 2 fits into 35 mm slide mounts for use in presentations.
  • Bitewing (size 3) film measures 11¼16 by 21¼8 inches. Size 3 films adapt well to the mandibular cheek teeth.
  • Occlusal (size 4) film measures 21¼4 by 3 inches. Occlusal film is used to radiograph large breeds.
  • D speed (Ultraspeed, Kodak) provides high contrast and fine detail. Ultraspeed is the most popular film used in veterinary dentistry.
  • E speed (Ektaspeed, Kodak) requires 25 percent less exposure time, compared to D speed film, with minimal loss of contrast.
  • F speed (InSight, Kodak) requires 60 percent less exposure time than D speed film, and 20 percent less than E speed film.
  • Viewing pathology below the gingiva and inside the tooth documenting the presence of lesions to support treatment decisions.
  • Evaluating an area where the teeth are not clinically apparent for root fragments.
  • Determining the cause of chronic nasal discharge.
  • Evaluating tooth vitality
  • Evaluating the number of permanent teeth present in a puppy or kitten as part of a detailed soundness examination before the secondary teeth erupt. Some breeds must have a minimum number of teeth to be accepted in the show ring.
  • Anatomical orientation and documentation of root structure before extraction.
  • Evaluation after extraction to confirm all root fragments were removed.
  • Pre-operative evaluation of gross tumor margins to help plan surgery.
  • Treatment planning evaluation when periodontal disease is present (gingival bleeding on probing, tooth mobility, gingival recession, furcation exposure, increased probing depths).
  • Evaluating feline odontoclastic resorptive lesions (FORLs).
  • Evaluating jaw fractures.
  • Evaluating oral and facial swellings.
  • Evaluating pre-operative, intra-operative and post-operative endodontic treatment.

Bookmark this article! [?]

BlinkbitsBlinkListsBlogLinesBlogmarksBuddymarksCiteULikeCo.mmentsDel.icio.usDiggDiigo

FarkFeed Me LinksFurlGoogleLinkagogoma.gnoliaMister WongNewsvinePropellerRawsugar

RedditRojoSimpySphinnSpurlSquidooStumbleUponTailrankTechnoratiYahoo

Anesthesia safety: Face your clients’ main concern about dentistry

pic1

A disturbing e-mail arrived the other day: Hello, Dr. Bellows: I have a 5-year-old yellow Labrador Retriever that I have routinely cleaned her teeth (with enzyme toothpaste and a brush, recently using Sonicare). Despite all best efforts, she is building up tartar and I think may have a dark spot (cavity on a rear molar).

I appreciate your time and hope you can provide some insight. Our Labrador has had general anesthesia several times, but I’m a bit skeptical to put her under anesthesia unless it is absolutely necessary.

I have seen some advertisements for non-general dental cleaning and was wondering if you are familiar with other anesthesia options? Can cleanings be done with IV sedation or simple acepromazine? Or do you intubate to protect the airway from debris?


Photo 1: Technician cleaning a dog’s teeth under general anesthesia

Client anxiety about anesthesia for dental procedures is a concern that practitioners face every day. Choosing the correct patient, anesthetic protocol, as well as intra- and post-operative monitoring allows the most favorable anesthesia outcome. How can you convey that anesthesia is necessary to perform dental procedures, and that it is well worth the smallest risk as long as precautions are taken?

Client anxiety about anesthesia is similar to dread of flying — fear of the unknown. To allay this trepidation, we take time to explain what happens and what we do to make the experience as safe as possible.

Case for anesthesia

To evaluate and clean teeth properly, general anesthesia is mandatory. Some veterinarians and non-veterinarians advertise anesthesia-free dentistry. This is a disservice to the patient, client and our profession.

The American Veterinary Dental College (AVDC) developed a position statement for veterinarians and the public. The AVDC prefers to use the more accurate term non-professional dental scaling (NPDS) to describe anesthesia-free dentistry.

Naturally, owners of pets are concerned when anesthesia is required. However, performing NPDS on an unanesthetized pet is inappropriate for the following reasons:  

Professional dental scaling includes scaling the surfaces of the teeth above and below the gingival margin (gum line), followed by dental polishing. The most critical part of a dental scaling procedure is scaling the tooth surfaces that are within the gingival pocket (the subgingival space between the gum and the root), where periodontal disease is active. Because the patient cooperates, dental scaling of human teeth performed by a professional trained in the procedures can be completed successfully without anesthesia. However, access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient. Removal of dental tartar on the visible surfaces of the teeth has little effect on a pet’s health, and it provides a false sense of accomplishment. The result is purely cosmetic.  

What can you do?

Choose the correct patient

When a client asks whether his or her dog or cat is too old for anesthesia, remember age is not a disease. However, older patients often are discriminated against that need urgent dental care to decrease pain and improve quality of life. No amount of antibiotics is going to help a companion animal suffering with mobile teeth secondary to Stage 4 periodontal disease. My point: Letting the periodontal syndrome rage on is far more dangerous than professional oral hygiene care performed under general anesthesia.

Every patient must be evaluated before anesthesia. The patient history is a vital part of the preoperative process and in some cases will clue the practitioner of potential problems better than lab results and radiographs.

When the physical exam is normal in our office, age-appropriate and condition blood tests and electrocardiograph evaluations are performed. Thanks to the advent of easy-to-operate, economical blood analyzers, which deliver almost instantaneous valuable results, and handheld electro-cardiographic devices, all anesthetic procedures are preceded with patient blood analysis and ECG (Photo 2). Much like a pilot performing a pre-flight checklist, run through a list of critical systems beforehand. I also want to know as much as possible about the patient. Argument can be made that preanesthetic testing lacks evidence-based medical rational (preanesthesia lab testing and ECG equals or does not equal a successful anesthetic event), if you compare preoperative testing to a pilot’s preflight checklist, both the veterinarian and pilot want to know as much as practically possible before an event. It just adds to our comfort knowing as much about our patient as practical before performing a procedure that will drastically alter its current status. Additionally, the testing makes the client feel more secure. Before dental anesthesia, my own clinically normal 4-year-old Lowland Sheepdog’s blood work revealed a 3.9 creatinine, albumin 1.9, urine specific gravity 1.014 with 3+ protein and a urine-protein-creatinine ratio of 6.2!

For procedures expected to last less than two hours, our protocol is:  

If all the preoperative tests are normal before the patient is anesthetized in our office, the doctor signs off on the case. Much like our pilot example, the procedure helps confirm that the tests were performed and evaluated.

The correct anesthesia protocol

Anesthesia protocols vary by patient age, condition, co-morbidity factors, length of and type of procedure. Local anesthetics are used on all operative dental procedures where tissue is incised. There are many anesthesia protocols; the best one is the one that you are most comfortable with. Here is the one that has met with success in our office:  

For healthy dogs, our first choice is hydro-morphone 0.1 to 0.2 mg/kg or morphine 0.5 to 1.0 mg/kg combined with acepromazine 0.010 to 0.040 mg/kg. No anticholinergic unless patient demonstrates need, are pediatric or brachycephalic.

As they become more debilitated or aged, we shift toward hydromorphone 0.1 to 0.2 mg/kg alone or with midazolam 0.2 to 0.4 mg/kg. Still no anticholinergic unless specific need.

For healthy cats, our first choice is hydro-morphone 0.2 mg/kg or butorphanol 0.2 mg/kg combined with medetomidine 0.010 to 0.015 mg/kg, plus atropine.

As cats become more debilitated or aged, we use butorphanol 0.2 mg/kg or hydromorphone 0.2 mg/kg with 0.2 to 0.4 mg/kg midazolam. Ketamine is added 1 to 5 mg/kg as needed if fractious and not HCM cats. [HCM cats get a touch of medetomidine (0.005 mg/kg) as the next step.]
Induction agents (ket/val, propofol, etomidiate) are given intravenous after catheter placement.

Anesthesia is generally maintained with isoflurane or sevoflurane and oxygen. Little isoflurane or sevoflurane is metabolized, the insolubility of the inhalants allows for a speedier induction and recovery. Patient temperature is controlled in many ways including blankets, warm intravenous bottles placed next to the patient under the blankets, and a warm air Bair Hugger.

Intraoperative local anesthesia blocks are used to decrease pain, and the need for excessive anesthesia when painful procedures and contemplated.

Patient monitoring

The third leg of the anesthetic safety trilogy is evaluating the patient while anesthetized and after. Anesthesia monitoring varies from observing respiration and noting mucous membrane color refill, to arterial blood gas evaluation. American Animal Hospital Association (AAHA) anesthesia guidelines require that one or more of the following monitors must be used on the anesthetized patient:  

As with any complicated endeavor, it is far better to know more. Some manufacturers incorporate multiple monitors into a master unit.

Electrocardiogram

ECG evaluations before and during anesthesia give the veterinarian information regarding heart rate, rhythm and abnormal complexes. Lead 2 is primarily used to monitor rate and rhythm in patients under anesthesia. Handheld units used as part of the pre-operative patient evaluation can also perform single-lead continuous readings during the dental procedure.

Electrocardiograms can also be generated using esophageal probes. While anesthetized, the probe is inserted into the esophagus until the distal electrode reaches the area dorsal to the heart base. If the ECG tracing appears small, the probe may not be inserted far enough. If inserted too deep, the tracing can appear inverted.

The electrocardiogram gives minimal information on cardiac contractility and tissue perfusion. Presence of normal-appearing complexes does not indicate the patient’s tissues are adequately perfused. The ECG should be used with another form of monitoring (end tidal CO2 and/or blood pressure) for patient evaluation during anesthesia.

Respiratory monitor

Respiratory depression from anesthetic premedication, induction agents and inhalant anesthetics occur. The effects of these medications are dose-dependent and, when multiple agents are used, may become synergistic.

Apnea monitors alert the clinician when the patient’s respiratory rate is depressed or stops. Most respiratory monitors detect exhaled airflow. The sensor is attached between the endotracheal tube and anesthesia machine’s delivery tubes. Every time the animal exhales, the monitor emits an audible sound. When choosing an apnea monitor, it is important that the signal is loud enough to easily hear over the ambient noise and that an alarm sounds when breathing stops.

Pulse oximeter

Hemoglobin travels through the blood in two forms: oxyhemoglobin and reduced hemoglobin. Most oxygen transported to the tissues is carried on the hemoglobin molecule. The pulse oximeter estimates the patient’s oxygenation via light absorption measurement of arterial hemoglobin oxygen saturation. One of the most effective placements of the oximeter probe is on the tongue. Dental procedures by their nature involve movement and instruments in the mouth, which often dislodge the tongue oximeter probe. Other areas for probe placement include the pinna, toe, prepuce, vulva, metacarpus (tarsus), digits, tail and rectum.

Oxygen saturation should be maintained between 95 percent and 100 percent, particularly if the animal is breathing 100-percent oxygen. Saturation readings of 90 percent or less indicate marked desaturation, hypovolemia, shock or anemia.

  • Electronic respiratory monitor
  • Pulse oximeter
  • Blood-pressure monitor
  • Continuous electrocardiograph (ECG) monitor
  • Esophageal stethoscope
  • End-tidal CO2 monitor

 

 

The oximeter measures only the level of oxygen saturation and heart rate, which may be elevated when the patient hyperventilates in response to discomfort. Unfortunately, a hyperventilating patient also can inhale excessive anesthetic progressing to hypovolemia. Pulse oximeters do not measure how forcefully the heart is beating.
Blood pressure measurement

In human medicine, blood pressure measurement is part of most examinations and constantly evaluated under general anesthesia. In small animal practice, blood pressure measurement is equally important. The mean arterial pressure (MAP) should be greater than 60 mm Hg under anesthesia. If blood pressure drops below this level, the anesthetic concentration should be lowered.

Noninvasive blood pressure measurement uses a cuff placed around the patient’s limb or tail at the level of the heart. In cats, the tail base may have to be clipped. The cuff diameter should be 40 percent of the circumference of the limb or tail base (3 cm in cats, 4 cm for small dogs, and 5 cm and up for larger dogs). Normal readings for anesthetized dogs and cats are systolic 90-105 mm Hg, diastolic 40-60 mm Hg, mean 60-70 mm Hg.

Commonly used types of noninvasive blood pressure monitors include:  

Pressure-plethysmography provides systolic, diastolic and mean pressure using an inflatable cuff to occlude blood flow, and a sensor is placed distal to the cuff to detect arterial pulsation. The cuff is wrapped above the carpus, tail or below the hock, and the sensor placed on the same limb just below the cuff. Accurate placement over an artery is not essential. The cuff automatically inflates to a pressure, which occludes the underlying arteries and then deflates gradually. When the cuff pressure is equal to systolic arterial pressure, flow proceeds and arterial pulsation returns. After systolic and diastolic arterial pressures have been determined, the computer calculates the mean pressure.

Carbon dioxide measurement

Carbon dioxide is produced by all cells, transported by the circulatory system and eliminated through the lungs. Alveoli are sites of gas exchange. The highest concentration of carbon dioxide should occur at the end of expiration when the diluted gases from the trachea and primary bronchi are no longer being sampled. Changes in carbon dioxide levels reflect changes in metabolism, circulation and respiration. Measuring expired carbon dioxide allows an estimation of arterial CO2, which lets the veterinarian know whether the anesthetized patient is ventilating adequately.  

Blood-gas acid/base monitoring

Blood-gas acid/base measurement can provide useful information in the anesthetized patient. While capnography and pulse oximetry give an indirect indication of respiratory function, direct measurement of pO2 and pCO2 can be made using arterial blood-gas measurements (obtained from the femoral or lingual artery). Typically, these measurements are done serially as rapid changes can occur with changes in the patient’s respiratory function. As such, these parameters are sensitive indicators of what is at times a challenge in the compromised patient under anesthesia.

  • Increased CO2 readings can be seen due to the following:
  • Mild to moderate airway obstruction
  • Hypoventilation
  • Faulty check valves
  • Exhausted soda lime
  • Decreased CO2 readings can be seen due to the following:
  • Hyperventilation
  • Extubation
  • Disconnection from the breathing circuit
  • Esophageal intubation
  • Cardiac arrest.
  • Doppler that measures systolic arterial pressure. The pitch of the sound reflected from the moving blood cells is proportional to its velocity. A piezoelectric crystal microphone, amplifier, inflatable cuff, manometer and earphones are used. An ultrasonic flow detector is placed over an artery and taped in place. A cuff is placed proximal to the crystal and inflated until blood flow is occluded. The cuff is slowly deflated. The pressure at which blood flow becomes audible again is the systolic pressure.

 

 

While venous blood gas is not as sensitive for measuring respiratory function, it can give valuable information about a patient’s acid/base status. Acid/base condition is affected by both respiratory and cardiovascular function and as such is a valuable indicator in the anesthetized patient. Look for acidosis when CO2 accumulates due to compromised respiratory function, or when cardiovascular compromise leads to poor tissue perfusion. Analyzing the values also will indicate the degree the patient has compensated for the abnormality.
When the PCO is increasing (pH decreasing) and PO2 is dropping, the patient needs to be ventilated and the endo-tracheal tube evaluated for patency as well as the soda lime checked for expiration. If PCO2 is too low (and PH increasing), then the patient is over ventilating.

Temperature monitoring

Temperature control and monitoring is important for dental patients. Dental procedures often last hours, during which the animal may be exposed to air conditioning and water irrigation. As the patient temperature decreases, so does the blood pressure and heart rate. Temperature monitors can be as straightforward as a technician inserting a rectal thermometer every 15 minutes and recording results, to a real-time constant digital evaluation.

Putting it all together….

Molly, a 16-year-old Poodle was presented to our office for dental care. Her owners, two general surgeons, could not tolerate her breath; even guests in their homes complained. As soon as I entered the exam room, I knew this dog was in dental trouble; the odor was intolerable.

Why did these highly educated, loving pet owners let poor Molly suffer so long? For the first 10 years of her life, they were afraid of anesthesia, and for the last six, three veterinarians said she was too old to safely perform dental care.

This story has a good ending. After age- and condition-appropriate blood and urine tests, radiographs and electrocardiogram, she was placed under three hours of general anesthesia for extraction of 26 teeth. Two weeks post procedure, her owners were ecstatic to have a “new dog”.

How can we as veterinarians allay our client’s fear of anesthesia for dental procedures? The answer is threefold: choose the correct patient, the correct anesthesia protocol, and proper monitoring during and after the procedure, so everyone wins.

Dr. Jan Bellows owns Hometown Animal Hospital and Dental Clinic 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 (954) 349-5800; e-mail,

Bookmark this article! [?]

BlinkbitsBlinkListsBlogLinesBlogmarksBuddymarksCiteULikeCo.mmentsDel.icio.usDiggDiigo

FarkFeed Me LinksFurlGoogleLinkagogoma.gnoliaMister WongNewsvinePropellerRawsugar

RedditRojoSimpySphinnSpurlSquidooStumbleUponTailrankTechnoratiYahoo

Employ oral ATP in your fight for dental health

If you want to drive a veterinary dentist nuts, use the terms “dental, dentistry or prophy” in a sentence describing the oral hygiene and teeth cleaning visit.

Why get so bent out of shape over a word or two?

The big deal is two-fold. First, the choice of words is incorrect, and second, the process that is performed needs to include more than removing calculus from the crowns of teeth.

Referring to the procedure as a dental or dentistry is painting a broad brush of all possible dental diagnostics and care over patients that have different oral problems.

If a dog or cat is presented for an ovariohysterectomy, it is expected that the patient will be anesthetized, an incision will be made, the ovaries and uterus removed and the incision sutured. In most cases, an ovariohysterectomy is an ovariohysterectomy. It’s not the case with dental care. Virtually all cases are different even though the mouths smell similar. Some teeth are in Stage 1 periodontal disease and others have Stage 4. Some patients only need minimal oral hygiene care while most require oral surgery. Referring to what we do as a dental is similar to telling a client we need to do a cardiac on a dog who presents for respiratory difficulty, arrhythmia and Grade 3-5 heart murmur.

To call the procedure a prophy or prophylaxis opens up the next can of worms. Prophylaxis is a term used in human dentistry to describe the procedure performed by a dental hygienist usually in response to a postcard requesting your visitation to the dentist. There are a number of existing definitions for “oral prophylaxis” by the American Dental Association.

A common element in these definitions is the removal of deposits from the tooth surfaces. Most of these definitions only address supragingival deposit removal from coronal tooth surfaces and the clinical crowns of the teeth. The American Academy of Periodontology presents the most comprehensive definition of the oral prophylaxis as the “removal of plaque, calculus and stain from exposed and unexposed surfaces of the teeth by scaling and polishing as a preventive measure for the control of local irritational factors.”

Current definitions indicate that the oral prophylaxis is performed on patients/clients with normal, healthy mouths to maintain health and prevent the initiation of dental disease. When periodontal disease is present, removal of deposits on the teeth is no longer a preventive service. In the presence of periodontal disease, periodontal debridement (therapeutic scaling and/or root planing, also known as non-surgical periodontal therapy) is indicated.

The American Dental Association’s (ADA) Current Dental Terminology, second edition (CDT-2) states that the adult prophylaxis is “performed on transitional or permanent dentition, which includes scaling and polishing procedures to remove coronal plaque, calculus and stains.” It is intended for use on the patient/client without periodontal disease. Again, this is not what we do. Our clients schedule the oral hygiene care appointment once their pet has halitosis secondary to periodontal disease.

What should happen during the procedure, and what can we properly call the oral hygiene visit?

Three important actions

The procedure should be treated as three separate interrelated actions: Oral assessment, treatment and prevention (Oral ATP).

Assessment is the systematic collection and analysis of data in order to identify patient needs. Tooth-by-tooth evaluation of probing depths, mobility, furcation exposure, fractures, missing teeth, extra teeth, odontoclastic resorptive lesions, among other lesions, should be noted on the dental chart. Assessment is the first step needed to make a diagnosis and formulate a treatment plan.

Treatment: With 42 teeth in the dog and 30 in the cat each with different degrees of pathology, spending time to plan therapy makes sense. Some teeth need extraction due to support loss as a result of Stage 4 periodontal disease. Teeth affected with Stage 2 periodontal disease (<25 percent support loss) can benefit from locally applied antimicrobial (LAA). In some cases there is little pathology noted other than minimal plaque and calculus which are removed. Fractured teeth with pulp exposure are either preserved via root-canal therapy or extracted.

Prevention is one of the most important parts of the oral hygiene procedure. By cleaning the teeth, removing plaque and calculus above and below the gingiva and polishing, the mouth is “clean” for about six hours until plaque forms on the tooth surface unless a barrier is applied. If the patient is sent home without attention to prevention, there was little gained by the time, risk and expense incurred for oral hygiene care.

In our office, periodontal prevention begins before the animal awakens from anesthesia by applying a barrier sealant that electrostatically attaches to the tooth and is pressed subgingivally. Before leaving the office, the client is instructed how to control plaque through a specifically tailored program considering the willingness of pets and clients. At a minimum, we recommend clients feed their pets a VOHC-certified dental diet and weekly application of the plaque barrier gel. We teach other clients to brush their pet’s teeth twice daily with a toothbrush or dental wipe impregnated with sodium hexamethaphosphate.

Endodontic damage prevention entails inspection of the pet’s chew toys. Generally, removal of any device that is harder than the tooth (bones, hard nylon, ice cubes, cow hoofs) are recommended. Tennis balls also can wear away the occlusal surface causing crown and pulp damage.

An important part of prevention is the recall appointment for patients that have completed treatment.

Typically the recall interval is based on the degree of periodontal disease and the amount of home care. Generally Stage 1 gingivitis cases are rechecked twice yearly, Stage 2 every three months and Stage 3 and Stage 4 monthly. The recall appointment is an ideal time to evaluate the degree that the client has achieved home-care goals.

In the end, oral assessment, treatment and prevention is really what we are called on to do.

Dr. Jan Bellows owns Hometown Animal Hospital and Dental Clinic 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 (954) 349-5800; e-mail:

Bookmark this article! [?]

BlinkbitsBlinkListsBlogLinesBlogmarksBuddymarksCiteULikeCo.mmentsDel.icio.usDiggDiigo

FarkFeed Me LinksFurlGoogleLinkagogoma.gnoliaMister WongNewsvinePropellerRawsugar

RedditRojoSimpySphinnSpurlSquidooStumbleUponTailrankTechnoratiYahoo

Let technicians polish dental practice success

Behind every flourishing dental practice is a great veterinary staff. If you want to move forward with your veterinary dental practice, it’s time to get your technicians on board.

Photo 1: Properly attired technician examining a patient’s mouth.

Recently, there was an interesting discussion on the Veterinary Information Network concerning a veterinarian who wanted to “get into dentistry.” This doctor purchased a dental X-ray unit, and he expected the dental segment of his practice would just grow. The reality: Nothing happened.

His next move was to urge his technicians to obtain proper dental radiology continuing education. Still, the team didn’t bite. Out of frustration, he delivered a hard-line ultimatum. Unless his technicians became proficient in their role with dental radiology within three months, they would be fired.

The threats were in vain. He sought advice on what to do next. The answers from fellow VINers focused on training, compassion and reiterating the philosophy that learning is a journey, not a destination.

Table 1 Technician tasks

So what is the answer to this veterinarian’s dilemma? How does a veterinarian motivate his or her technicians so they can improve the medical delivery of dentistry to patients?

Jim Collins, in his book “Good to Great,” analogized that successful company leaders acted as bus drivers steering their company in the right direction. The “bus” needs to be loaded with the right people, and they need to be in the correct seats. This analogy is very appropriate for our practice team as they work to deliver oral assessment, treatment and prevention of veterinary dentistry. The practice owner needs to decide the extent of dental services to offer — oral assessment, cleaning and prevention with non-surgical extractions; endodontics, orthodontics and/or oral surgery. This first (of three) articles will focus on the technicians’ critical role, followed by the veterinarian’s connection and finally address client responsibilities.

Who’s driving anyway?

Photo 2: Sterile examination pack.

You would think that the veterinarian acts as the driver for veterinary dentistry: not true. In most practices, veterinary technicians often determine the success or failure of this important veterinary discipline. Without trained, capable and eager technicians, the “bus” and journey can only go so far.

Roles delineated

When it comes to organizing veterinary dentistry delivery within a practice, the veterinary technician should be assigned important duties from equipment and material procurement, maintenance, sterilization, procedure preparation, information gathering (probing, charting, X-rays), teeth cleaning, polishing, barrier gel application as well as client education before, during and after these procedures (Photo 1).

Equipment and material management

Here are some duties to consider for your technicians:

  • Preparation of dental packs.
  • Sterilization of dental instruments.

Technicians are responsible for preparation and sterilization of ovariohysterectomy, and orthopedic instrument packs which group instruments and materials for a specific purpose together. The technician should also prepare and sterilize dental specific “trays” for examination, non-surgical extraction, surgical extraction as well as advanced endodontic and periodontal surgery. In some practices, this will necessitate purchasing additional instruments. Fees for “sterile extraction surgical pack”, or “sterile oral examination pack” are well accepted by clients (Photo 2).

As with human dentistry, sterility of instruments that enter patient’s mouths is important to prevent infection as well as cross contamination. Individual see-through packets are available from veterinary distributors for instrument sterilization.  

Equipment maintenance is critical to the successful dental practice. Many of the hand instruments (scalers, curettes, luxators, periosteal elevators) must be sharp to work correctly. A human dental hygienist can easily teach sharpening techniques. Ultrasonic scaler tips should be inspected before each teeth cleaning to make sure they are not broken (Photo 3). High-speed, water-cooled dental delivery systems must be maintained according to the manufacturer’s instructions (Table 1 and Photo 4).

Procedure set up

Technicians must understand the steps involved in different dental procedures in order to predict what equipment and material the veterinarian plans to use.

It is the technician’s responsibility to gather equipment and materials for the procedure at hand before the patient is anesthetized. If oral surgery is planned, placing all the equipment, instruments and materials within reach saves countless minutes and wasted time.

Anesthesia  

Let technicians be the guide: key duties

In many offices, the trained veterinary technician administers medication to anesthetize the patient under the veterinarian’s direction. Monitoring equipment is connected to evaluate the patient’s vital signs. It is up to the technician to make sure the monitor’s cuffs and wires are in working order before anesthesia begins and that the connections transmit correct information during the entire procedure. Dental procedures can be lengthy leading to hypothermia. The technician shares responsibility for proper temperature maintenance. The technician’s anesthesia responsibility does not end until the patient is in sternal recumbency (Photo 5).

Dental information  

The technician provides information to the doctor on a dental chart. The difference between information and diagnosis is important for all parties to understand. Gross findings (probing depths, mobility scores, missing teeth), diagnosis and development of a treatment plan is left to the veterinarian once information is delivered and reviewed.

Generally, the technician performs coronal scaling, compiles information on the dental chart after a tooth-by-tooth evaluation, exposes and processes oral survey radiographs for review. After dental treatment, the technician performs fine coronal and sulcar scaling, polishing, sulcar lavage and application of the plaque barrier gel if indicated (Photo 6).

Client communication

Dental disease prevention is as important as the other dental disciplines. Here, the technician acts as an extension of the veterinarian counseling clients on how to keep their pet’s teeth and gingiva healthy.

The technician also acts as the practice’s voice on dental subjects — from fielding intake questions to demonstrating brushing techniques. Many practices appoint the technician most knowledgeable in dental care to make dental appointments. This works very well preparing the client what to expect during the oral assessment, treatment and prevention visit.

Getting results

Where can the practice owner send their interested technicians to get the necessary dental knowledge?

I could feel the frustration of the veterinarian featured at the beginning of this article. All he wanted to do was expand his practice’s capabilities and service with diagnostic radiographs in dentistry. To date, there are no full or part-time veterinary dental hygiene schools. The more you can read, see, hear and practice, the better.

Continuing education courses including hands-on wet labs on dentistry are listed on http://www.veterinarydentalforum.com/calendar.cfm.

The annual Veterinary Dental Forum contains three days of high-quality programming with presentations in several tracks to suit anyone from the beginner to the expert, plus hands-on laboratory sessions and reports on the latest research in veterinary dentistry. The upcoming Veterinary Dental Forum is Sept. 21-24, 2006 in Portland Oregon.

Dental textbooks concentrating on dental technician education:  

Aim for the stars

The Academy of Veterinary Dental Technicians (AVDT) received approval as a technician specialty organization by the National Association of Veterinary Technicians in America (NAVTA). Since 2000, charter academy members have worked with NAVTA and the American Veterinary Dental College to prepare credential requirements and a certification examination. On June 17, the first examination was administered in Baltimore.

The AVDT is in the process of setting up the appropriate continuing education lectures and wet laboratories, and other support for staff interested in the field of veterinary dentistry. Anyone interested in further information on the academy should log on to its Web site at http://www.avdt.us/.

Our next article will explain how to make dental decisions based on the information the your dental technician provides.

Dr. Jan Bellows owns Hometown Animal Hospital and Dental Clinic 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 (954) 349-5800; e-mail:

  • Veterinary Dentistry for Technician & Office Staff-Holmstrom, 2000, Elsevier
  • Atlas of Veterinary Dental Radiology, An-DeForge,III, 2000, Blackwell Publishing
  • Small Animal Dentistry, Mitchell, 2002, Elsevier
  • Veterinary Dentistry for the Nurse and Technician – Gorrel, Derbyshire – 2005
  • Veterinary Dentistry for Small Animal Technician-Kesel, 2000, Blackwell Publishing.

  • The technician spends more tooth-by-tooth time with patients, so access to quality information, including X-rays, is imperative to create a sound dental treatment plan. Remember X-rays should be properly exposed and processed, and they provide an essential piece to the dental puzzle.
  • The technician is involved in anesthesia from induction to arousal.
  • Keep the monitoring equipment in working order (can be challenging).
  • Technician maintains dental equipment.
  • Technician keeps hand tools sharp.

Bookmark this article! [?]

BlinkbitsBlinkListsBlogLinesBlogmarksBuddymarksCiteULikeCo.mmentsDel.icio.usDiggDiigo

FarkFeed Me LinksFurlGoogleLinkagogoma.gnoliaMister WongNewsvinePropellerRawsugar

RedditRojoSimpySphinnSpurlSquidooStumbleUponTailrankTechnoratiYahoo

Intraoral films: 7 compelling reasons for every dental patient

According to industry estimates, less than 10 percent of small animal practices have dental radiograph units and of those, less than 10 percent take intraoral films on every dental case.

That equates to only 1 percent of the dogs and cats placed under general anesthesia for oral assessment, treatment and prevention (oral ATP) visits get the benefit of survey films.

Reasons given for not taking films include client resistance due to radiation exposure and additional fees, difficulty in exposing and processing films, film interpretation and the added anesthetic time. They are all valid reasons but not insurmountable with proper equipment, dedicated dental radiograph unit and digital sensor, training and client education. In an article published in the Journal of Veterinary Research, Dr. FJ Verstraete et al found that significant dental lesions were noted in 70 percent of the cases in dogs and approximately half of the cats studied.

Photo 1a: Dylan

Hopefully after reading these seven additional reasons to take intraoral films, some of the practitioners not taking dental films routinely will change their minds. All of these reasons came from my general practice from pets presented for teeth cleaning.

Reason 1: Dylan, a 7-year-old mixed dog, presented for an oral ATP visit. Physical examination showed a moderate amount of plaque and calculus. The right mandibular fourth premolar slightly overlapped the first molar. Full-mouth survey films revealed significant bone loss between the mesial root of the right mandibular first molar and the distal root of the third premolar.

Treatment consisted of exposing the area via gingival flap, curettage and placement of an osteoconductive material (Consil® Nutramax) with a guarded prognosis (Photos 1a, 1b and 1c).

Reason 2: During the initial assessment of Fred, a 4-year old Yorkshire Terrier, a right maxillary second incisor fracture was noted. Clinically, pulp exposure was not present. Full-mouth survey films revealed a 3-mm by 3-mm periapical lucency around the right maxillary second incisor extending to the third incisor. The fractured tooth was extracted (Photos 2a, 2b, 2c, 2d and 2e).

Reason 3: Marshmello, a 3-year-old Maltese, presented for an oral ATP visit. Assessment under anesthesia revealed slightly mobile right maxillary second and third premolars. Intraoral radiographs revealed deciduous teeth with greater than 75-percent bone loss. The affected teeth were extracted (Photos 3a, 3b and 3c).

Reason 4: Puggles a 5-year-old Pug presented for halitosis. Physical exam revealed gingival recession approaching the mucogingival line of the left maxillary fourth premolar and rotated second and third premolars. Intraoral radiographs revealed almost complete bone loss rostral to the mesial root of the left maxillary fourth premolar as well as support loss of the second and third premolars. The affected teeth were extracted (Photos 4a 4b and 4c).

Reason 5: A 2-year-old Basenji, Kody’s physical exam under anesthesia revealed slight inflammation and edema surrounding the right mandibular second molar. Intraoral films confirmed bone loss around the furcation as well as >50-percent bone loss around the mesial root. The mandibular second molar was extracted (Photos 5a, 5b and 5c).

Reason 6: Max, an 8-month-old Brussels Griffon, presented for neutering. Physical examination under anesthesia revealed a clinically missing right mandibular first premolar. Intraoral radiographs revealed a rostrally impacted first premolar. To avoid a future dentigerous cyst and periodontal disease, the tooth was extracted via flap exposure (Photos 6a, 6b and 6c).

Reason 7: Buddy, an 8-year-old cat, presented for an oral ATP visit. Physical examination showed minimal inflammation surrounding the left mandibular third premolar. Intraoral radiographs revealed marked internal and external resorption. The tooth was extracted via flap exposure (Photos 7a, 7b and 7c).

By Dr. Jan Bellows