The ABCs of veterinary dentistry: Brought to you by the letter "D"

We've only just begun discussing the fundamentals of companion animal dentistry (check out the breakdown of letters "A," "B" and "C," anesthesia and basic concepts, here), and there's more to come. "D," of course, stands for "dentistry," with an honorable mention of "dentin" and "dentigerous cyst" for good measure.

But let's reflect on dentistry for a moment. What does it do for you in practice, and how can you share your passion to do what's right for your patients with their caregivers?

First, let's look at the entities that are dedicated to the advancement of veterinary dentistry. There are three nationally recognized veterinary dental organizations.

1. The American Veterinary Dental College (AVDC.org) has as its primary objectives to (1) determine the standards required for recognition of board-certified veterinary dental specialists and (2) conduct the credentials review and examination procedures necessary to identify veterinarians who have reached the "specialist" veterinary dentist standard.

In addition to ensuring that diplomates provide expert care to individual patients, the AVDC plays a major role in preventing oral disease by sponsoring the Veterinary Oral Health Council (VOHC), which awards the VOHC Seal of Acceptance to oral home care products that meet the standards of effectiveness in dental plaque and calculus control.

2. The Foundation for Veterinary Dentistry (F4VD.org) operates exclusively for charitable, scientific and educational purposes. It was founded to inform the public of the importance of oral health in animals and to advance the understanding of the science of veterinary dentistry among all members of the profession. To accomplish this, the foundation:

> provides funding assistance to colleges of veterinary medicine and veterinary technician schools along with other institutions, entities and individuals to enhance the education of students

> provides appropriate equipment to facilitate teaching and delivery of effective oral care

> awards funding for research projects in the field of veterinary oral health.

The F4VD is responsible for publishing the Journal of Veterinary Dentistry and the annual Veterinary Dental Forum.

3. The Academy of Veterinary Dentistry (AVD) is an international organization of veterinarians with a special interest in the dental care of animals. Most of the members are active practitioners serving the oral health needs of their patients. Some work with exotic animals in the wild and at exhibition parks and zoos. Others are involved in research, teaching, consulting and medical sales. The AVD is closed for additional membership.

More than a "dental": Brush up on your terminology

In companion animal practices across the country, dogs and cats receive "dentals" daily. But the term "dental" barely explains what's involved. Fortunately, the AVDC provides us with the following definitions:

Veterinary dentistry is defined as a discipline within the scope of veterinary practice that involves the professional consultation, evaluation, diagnosis, prevention, treatment (nonsurgical and surgical) of conditions, diseases and disorders of the oral cavity and maxillofacial area and their adjacent and associated structures. It is provided by a licensed veterinarian consistent with the ethics of the profession and applicable law.

Professional dental cleaning refers to scaling (supragingival and subgingival plaque and calculus removal) and polishing of the teeth with power or hand instrumentation by a trained veterinary healthcare provider under general anesthesia.

Periodontal therapy refers to treatment of diseased periodontal tissues that includes professional dental cleaning as defined above and one or more of the following: root planing, gingival curettage, periodontal flaps, regenerative surgery, gingivectomy or gingivoplasty, and local administration of antiseptics or antibiotics.

Home oral hygiene refers to measures taken by pet owners that are aimed at controlling or preventing plaque and calculus accumulation.

The steps of good dental care

At All Pets Dental we refer to the anesthetized oral exam, dental cleaning and treatment performed under anesthesia, plus any prevention recommendations, as "oral ATP."  Other practices call this COHAT, or comprehensive oral health assessment and treatment. Either way, it's a lot more than "doing a dentistry."

With guidance from veterinary dentists, certified veterinary dental technicians and hospital managers, the American Animal Hospital Association (AAHA) published the Dental Care Guidelines for Dogs and Cats in 2013. These guidelines outline the steps involved in the professional dental cleaning and the periodontal therapy visit. Our practice uses these guidelines (albeit in a different order) to streamline the workflow as much as possible. Here's the breakdown of what we do:

1. Perform an oral evaluation of the conscious patient (Figures 1A and 1B).

Figure 1A: A doctor placing a thiol diagnostic test strip in a dog's mouth.

Figure 1B. A strip highly positive for the presence of thiols related to gram-negative bacteria typical in periodontal disease.

2. Radiograph the entire mouth using an intraoral radiographic system. Radiographs are necessary for accurate evaluation and diagnosis. In one published report, intraoral radiographs revealed clinically important pathology in 28% of dogs and 42% of cats when no abnormal findings were noted on the initial examination.1,2 In patients with abnormal findings, radiography revealed additional pathology in 50% of dogs and 54% of cats. Due to superimposition, standard views of the skull are inadequate when evaluating dental pathology (Figures 2A to 2G).

Figure 2A. Imaging of the rostral maxilla.

Figure 2B: A left maxillary first incisor root fragment (red arrow) and stage 4 right and left canine tooth resorption (yellow arrows).

Figure 2C: Right maxillary canine and third premolar tooth resorption (yellow arrows) and fourth premolar root fragments (red arrows).

Figure 2D: Left maxillary canine, third and fourth premolar tooth resorption.

Figure 2E: Rostral mandibular canine root resorption.

Figure 2F: Left mandibular third and fourth premolar and molar tooth resorption.

Figure 2G: Left mandibular third premolar root fragments (red arrows) and fourth premolar and first molar tooth resorptions (yellow arrows).

3. Scale the teeth supragingivally and, most important, subgingivally using either a hand scaler or appropriate powered device followed by a hand instrument (curette). Do not use a rotary scaler, which excessively roughens the tooth enamel (Figures 3A to 3C).

Figure 3A: Ultrasonic scaling with proper eye, face and hair protection.

Figure 3B: To prevent iatrogenic damage, the side (not the tip) of the scaler is the only part of the instrument that should touch the tooth.

Figure 3C: Side of the ultrasonic scaler correctly placed against the surface of the tooth.

4. Polish the teeth using a low-speed handpiece running at no more than 300 revolutions per minute with prophy paste that is measured and loaded on a disposable prophy cup for each patient to avoid cross-contamination (Figure 4).

Figure 4: Polishing the teeth using prophy paste.

5. Perform subgingival irrigation to remove debris and polishing paste and to inspect the crown and subgingival areas (Figures 5A and 5B).

Figures 5A and 5B: Irrigation and air pressure used to examine for remaining plaque and tartar.

6. Evaluate the patient for abnormal periodontal pocket depths with a periodontal probe. The depth that is considered abnormal varies depending on the tooth and the size of the dog or cat. In medium-sized dogs, the probing depth should not be greater than 2 mm; in midsized cats, the depth should not be greater than 1 mm (Figures 6A and 6B).

Figures 6A and 6B: Abnormal 2-mm probing depth in a cat.

7. Perform periodontal therapy based on radiographic findings and probing.

8. Administer perioperative antibiotics when indicated, either parenterally or locally (Figure 6C).

Figure 6C: Local antimicrobial application to the pocket to help decrease the pocket depth.

9. Perform periodontal surgery to remove deep debris, eliminate pockets and extract teeth. When either pockets or gingival recession is greater than 50% of the root support, extraction or periodontal surgery is indicated and should be performed by a trained veterinarian or referred to a specialist (Figure 7).

Figure 7: Rongeurs used as extraction forceps.

10. Obtain a biopsy sample of all abnormal masses that are visualized grossly or noted on radiographs. Submit all samples for histopathology to be analyzed by a pathologist qualified in oral tissues analysis.

11. Take postoperative radiographs to evaluate the treatment applied. This is especially important in extraction cases (Figure 8A and 8B).

Figure 8A: A radiograph of the left mandibular first molar distal root affected by advanced periodontal disease.

Figure 8B: A radiograph confirming complete extraction.

12. Examine and rinse the oral cavity. Remove any packing or foreign debris.

13. Apply antiplaque substances, such as sealants (Figures 9A to 9C).

Figure 9A: A professional application of plaque barrier gel to the tooth surface.

Figure 9B: Application of plaque barrier gel subgingivally with help of the polishing cup.

Figure 9C: Application of dental sealant subgingivally to help prevent plaque.

14. Recommend referral to a specialist when the primary veterinary practitioner does not have the skills, knowledge, equipment or facilities to perform a specific procedure or treatment.

15. Provide instructions to the owner regarding home oral hygiene (Figure 10).

Figure 10. Give pet owners careful instructions on home dental care for their pets. Here the client is being instructed on how to use a Q-tip to remove the daily accumulation of plaque from the outside surfaces of her cat's teeth.

Veterinary dentistry is what you make it. When it becomes a passion at your practice, everyone wins. Don't miss the next stops along the alphabet of pet dental care: "E" for enamel and "F" for furcation, coming next month!

References

1. Am J Vet Res. 1998 Jun;59(6):686-91. Diagnostic value of full-mouth radiography in dogs. Verstraete FJ1, Kass PH, Terpak CH.

2. Am J Vet Res. 1998 Jun;59 (6), 692-695. Diagnostic value of full-mouth radiography in cats. Verstraete FJ1, Kass PH, Terpak CH.