Anesthesia and the dental patient (Proceedings)

The number one reason owners do not comply with regards to dentistry is the fear of anesthesia, not cost as some would believe.  Periodontal disease which occurs in over 85% of patients over the age of 5, has been shown to adversely affect the major organs of the body. The benefits of quality dental care far outweigh the risk of anesthesia. Let me say that again, the benefits of quality dental care far outweigh the risk of anesthesia.  Quality dental care has evolved and significantly improved over the past 20 years.  But general practitioners are still in the mindset of “teeth cleaning” or “doing a dental”.  There is a paradigm shift that has begun and is happening ever so slowly and the goal is to educate in the hopes of adding momentum to that shift.  The approach to dentistry, in order to raise the standard of care, needs to be thought of as not a “teeth cleaning”, but as a “prophy and assessment, with assessment and treatment being the most important component of the complete dental procedure. Cohat-an acronym being used in some practices-comprehensive oral health treatment and assessment.  Another acronym being used, ATP-assessment, treatment and prevention.   February has been the deemed as “pet dental health month” and many practices try to increase their dentistry procedures during that month.  Sometimes, 6-10 procedures scheduled in a day.  This is usually an indication that the full assessment and treatment portions are not occurring with these cases.  Unfortunately, this is not an appropriate standard of care with regards to the dental patient.  Full assessment includes radiology, probing and charting.  Treatment doesn't always mean extraction.  Dentistry is an elective procedure, and client compliance to adhere to once or twice a year procedures, can be challenging.  The veterinary team needs to educate the client in this regard, as well as alleviate the fears of the pet owner in order to gain compliance.  A discussion regarding the anesthetic protocols should take place at the time of the oral exam, at the time of admit or both.  It's important for the dental team to put the pet owner at ease before the procedure by answering questions and giving enough information.  The confidence of the dental and anesthesia team will also help to ease fears of the client. 

Dentistry vs. everything else

It's important to recognize that there are some significant differences between an elective procedure like a routine spay or neuter and a dental procedure.  There are significant differences in the procedure itself .  There are significant differences in the approach to our pain management of our dental patients which directly affects our anesthesia.  There are very specific things that we can do within the dental service that will ensure the success of the procedure. And the more successful the procedure the more compliant the owner will be to return for continued professional dental care. What constitutes a successful procedure. Number one-the patient goes home the same way it came in-walking and wagging its tail.  In the days following our dental procedure, we want our patients eating, drinking, and playing during the healing process.  If the patient goes home ataxic and painful, it's not likely they will return for continued dental care.    Dental procedures are longer, with the majority of patients being smaller, as most of the smaller breeds are prone to periodontal disease.  Unlike our routine surgeries, like spays and neuters, in most cases we aren't dealing with a young animal, the majority of these patients are older. 

Educate your clients.  Knowledge is power so empower your clients with the knowledge of what protocols that your practice employs to ensure the safety of their pet during anesthesia.  And for some clinics, this may be a wake up call to step up their specific practices within their hospital.  There are very specific things can be done to significantly reduce the risk of anesthesia. 

Preop workup

A thorough preoperative workup is the first step in minimizing the risk to the dental patient.  A minimal screening should include a CBC, chemistry panel and urinalysis.  More in-depth diagnostics can be done based on individual needs.

Protocols

Specific anesthetic protocols should be tailored to the needs of the patient.  Although, there are many agents and combinations of agents, it's important to keep in mind any underlying conditions when using specific drugs.  Narcotics are an effective premedication both for sedation and preemptive pain management.

Anesthestic monitoring

Anesthetic Monitoring-minimal parameters should include pulse oximetry, cardiac output (ekg), respirations, temperature and blood pressure.  End tidal CO2 is strongly recommended as well.  CO2 monitoring tends to be a much more sensitive measurement as to oxygen and CO2 levels because the CO2 receptor picks up subtle changes before the O2 receptor within the patient.

Ideally, an anesthesia technician is employed to monitor the patient while the dental team performs any dental procedures.  Parameters are recorded every 5-10 minutes and adjustments are made as needed.

Temperature and blood pressure monitoring are essential especially in the dental patient.

Essentials

IV catheter and fluids should be started and maintained throughout the anesthetic procedure to maintain volume and stabilize the patient's blood pressure.  IV fluids can be warmed as well to maintain body temperature. 

An endotracheal tube with cuff is used on every patient to maintain an open airway and prevent water and debris from entering the trachea and lungs.

An external heat source should be used to maintain body temperature.  A circulating hot water blanket, baer hugger, hot dog heating source are some of the more commonly used heating sources.  A heating pad is not recommended.  They have been known to cause burns in some patients.  Hypothermia is often encountered in the dental patient more prevalently than in other surgical patients.  Hypothermia can lead to reduced heart rate and respiration and if left unchecked, worst case death and best case, a slow recovery.   Dental procedures are often prolonged ranging from 45 minutes to 2 hours.   Water from the dental equipment also contributes to low body temperatures.   Hypothermia can be avoided in most patients by being proactive with a heating source and warmed fluids. 

Pain management

Effective pain management allows the anesthetist to keep the patient in a lighter plane of anesthesia.  Regional analgesia is an essential component as part of a multi modal approach. It prevents painful stimulus from reaching the cerebral cortex and allows for a lighter plane of anesthesia.  This greatly reduces the risk of complications including decreased cardiac output, respiration and blood pressure.  Regional blocks also aid in a smooth and pain free recovery. 

A successful anesthetic procedure in conjunction with a smooth and pain free recovery benefits not only the patient but also the pet owner.  The pet owner is more inclined to follow up with dental care if the first experience has a positive outcome.

Recovery

One of the most important steps just prior to recovery is the cleaning of the back of the throat.  Some folks will put gauze at the back of the throat and that keeps some of the debris from getting into the trachea.  But water and blood can still get passed that gauze. Gauze squares and cotton tipped applicators are used  to get passed the larynx and retrieve any water or blood that can accumulate before the cuff is deflated.

Post operative monitoring is critical for the dental patient.  Patients are monitored until they are sternal.  If the patient is pawing at the mouth, an elizabethan collar is placed.   The temperature should be monitored every 15 minutes until normal.  Hot water bottles should be placed in the cage for small patients.

A pain evaluation is done before the patient is discharged.