by Maureen Blaney Flietner

SOME PET OWNERS MAY THINK THAT NONANESTHETIC DENTISTRY (NAD) sounds like a good thing. But without a full examination of a pet’s mouth under anesthesia, the procedure is much like cleaning up the exterior of a vehicle while ignoring what’s under the hood. And the consequences can be tragic.

“Once I was presented a Cavalier King Charles spaniel champion show dog who had his teeth ‘cleaned’ every six months,” explained Daniel T. Carmichael, DVM, DAVDC, of the AAHA-accredited referral practice Veterinary Medical Center of Long Island. “At five years of age, he was brought to me for treatment because one of his incisor teeth had fallen out. An examination and dental radiographs obtained under general anesthesia showed severe (end-stage) periodontal disease with more than 20 teeth requiring extraction.

“In fact, I have seen this same scenario in many other patients over the years. Aside from the serious health implications to the patients, there is a sense of shock from the clients who mistakenly thought they were doing the right thing. Shock . . . then guilt.”

Sadly, Carmichael’s experience is not isolated.

“I have seen patients who have had NAD procedures for years and have teeth that look good on the surface,” said Kris Bannon, DVM, FAVD, DAVDC, of AAHA-accredited referral Veterinary Dentistry and Oral Surgery of New Mexico. “But when you get the pets under anesthesia and take radiographs and probe, I have found a significant amount of bone loss and gum recession and periodontal pockets on the inside surfaces of the back teeth. Without having the animals under anesthesia, they were not able to clean as needed and disease progressed in those areas to where it was too late.”

Review Your Step-by-Step Approach

These realities are a call to veterinary practices to not only better educate their clients and their entire team about the need for anesthesia in dentistry but also review protocols to make sure they are giving the procedures the priority they deserve.

Daniel T. Carmichael, DVM, DAVDC, of AAHA-accredited referral practice Veterinary Medical Center of Long Island	Kris Bannon, DVM, FAVD, DAVDC, of AAHA-accredited referral Veterinary Dentistry and Oral Surgery of New Mexico	Christopher Snyder, DVM, DAVDC, of AAHA-accredited University of Wisconsin–Madison School of Veterinary Medicine

To assist in that, the 2019 AAHA Dental Care Guidelines for Dogs and Cats provide a comprehensive approach in improving the oral health and quality of life of their canine and feline patients. The guidelines are an update of the 2013 AAHA Dental Care Guidelines for Dogs and Cats.

“The guidelines work as a reminder,” said Christopher Snyder, DVM, DAVDC, of AAHA-accredited University of Wisconsin–Madison School of Veterinary Medicine, who chaired the guidelines task force. “It’s a very step-wise approach for many hospitals that, in a hectic workday, might cut some corners or start dropping important steps because they have lost appreciation for their importance.”

Bannon noted that at times in general practice, dental procedures can have a little lower priority than the general surgery protocol.

“Some general practices tend to think it’s ‘just a dental,’ so the technicians do those while the doctors are doing surgeries they perceive to be more productive or more doctorly,” she said. “That is not the best way of handling it. The doctor needs to be involved, to be present, and at least two people should be involved in every process—one monitoring the anesthesia and another doing whatever needs to be done in the mouth.”

“It’s also important,” said Victoria Lukasik, DVM, DACVAA, of the College of Veterinary Medicine at the University of Arizona, that “very long procedures be staged into two or more shorter therapy sessions. There is objective evidence that both morbidity and mortality increase significantly after two hours of anesthesia time. Although morbidity and mortality increase in relatively healthy patients, this becomes especially more important in patients that have fragile physiology.

“When staging is the most appropriate for the patient, it is often thought to be too inconvenient for the client because a second visit is required. Dental care providers need to advocate for their patients and not be afraid to discuss or plan staging with clients when severe oral disease needs to be addressed.”

Be Up to the Task or Ready to Refer

If general practitioners don’t feel comfortable handling certain cases, it’s important that they refer those clients and not just tell them their pet is too old or too ill.

“Age of the pet is not an issue,” said Carmichael. “Old dogs and cats deserve a comfortable and healthy mouth as much as young ones, but underlying medical conditions are certainly a concern. As our patients age, the chances of them having underlying medical issues that can add risk to an anesthetic procedure increase as well. Patients with heart murmurs, for example, whose owners have been told that now their pet can no longer have anesthesia, can have procedures that have minimal to no risk if a veterinary cardiologist is brought into the case to modify the anesthesia protocol.

“Before deciding to go ahead with any professional dental treatment, a baseline of information needs to be obtained. This includes a physical exam, especially auscultation of the heart and lungs, and blood tests including complete blood count and blood chemistry analysis. If any abnormalities are detected, further preanesthetic tests should be considered.

“The good news is that with modern anesthetic drugs and protocols, combined with proper monitoring equipment and patient-warming systems, general anesthesia is better than 99.9% safe,” said Carmichael. “The other side of the coin is the risk to the patient if dental problems are not addressed. For most cases, the risks of not doing it by far outweigh the risk associated with well-performed general anesthesia.”

“The most important safety measure for pets undergoing anesthesia for dentistry, or any procedure for that matter, is the presence of a vigilant, dedicated person to monitor the patient’s vital signs throughout the entire anesthetic period,” said Lukasik. “Veterinary medicine has more opportunities for doctor and staff training than ever before, increasing the competence of all staff that monitor patients.”

And it’s only going to get better. In its August 30–September 1, 2020, meeting, the AVMA Council on Education approved revisions to Standard 9, Curriculum, including dentistry in the Standard.

Its rationale? The council believes that dentistry is an integral part of veterinary medical practice and is a crucial component for the health and welfare of multiple animal species. It is essential that students are trained in dentistry.

Reinforce Why Anesthesia Is Needed

It’s important that clients understand that not having anesthesia for dental procedures is not in the best interest of their pets. Among the reasons that experts offered:

• There is no way to comfortably clean underneath the gums, in between the teeth, and on the inside surface of every single tooth.
• It’s stressful and dangerous.
• Dental X-rays can’t be taken when pets are awake, leaving almost two-thirds of the tooth below the gum line unseen.
• Tooth surfaces can’t be polished. Scraping the tooth creates a microabrasion in the enamel. If not polished away, the area is going to retain more plaque.
• Probing and charting the teeth—an integral part of oral healthcare—is difficult to impossible to do without anesthesia.
• The pet’s airway is not protected. If breaking off calculus, chunks of plaque could be aspirated into the lungs.
• If a pet is stuck with a sharp scaler, the pet could bite the person and the pet will be averse to future cleaning or brushing.

Get the Whole Team on Board

“Present a unified message that oral care, attention to oral disease, and maintaining oral comfort are important,” said Snyder. “Make sure the client gets that same message from everyone in the practice during their visit.”

Provide copies of the AAHA guidelines for the entire staff to review, he suggested. The guidelines were written to “provide something that everyone from the technical support staff to the front-desk staff who have much less medical experience or background could get behind.” In addition, a hospital could review the guidelines at a team meeting.

Showcase patients familiar to the staff who had dental issues and are now doing better, said Bannon. After all, good oral health can be a life-altering experience, as she well knows. Bannon worked for 10 years in a small-animal hospital in Santa Fe. She said she was told by so many clients then about how the dental procedures she performed relieved pain they did not even know their pet had and made their pet active again that she went back to school to become a dental specialist.

Those before-and-after dental photos and X-rays that every practice reviews with its clients should be shared with staff, along with the comments received from owners about the improvements. Constantly sharing those types of stories with the whole staff is hugely helpful, Bannon explained. 

Maureen Blaney Flietner is an award-winning writer living in Wisconsin.

 

 

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Photo credits: vauvau/iStock via Getty Images Plus, photos courtesy of Daniel T. Carmichael, Kris Bannon, and Christopher Snyder; ©AAHA/Kimberly Lamb, ©AAHA/Kimberly Lamb