Bridging the compliance gap: Talk to clients about infection

Quality veterinary dental education for staff, technicians and practitioners is readily available. Many practices take advantage of courses and seminars to increase knowledge and upgrade dental-care equipment.

Brett Beckman

It's the next step that often brings frustration: Getting clients to comply with your recommendations.

The key is good communication – through building trust, education, using digital images, handouts and other means. Communication can make the difference between a pet that receives proper oral care and one that continues to suffer from oral disease.

Photo 1A: This patient is missing the first two mandibular left premolars.

First establish client trust

Even the best efforts toward dental-treatment compliance will fail unless first you win the client's trust. How can you do that? Here are some suggestions:

• Walk into the exam room with a smile, shake the client's hand and introduce yourself.

• Acknowledge the pet verbally and by holding or petting.

• Remember names. Use the names of the client, the pet and others in the room frequently during the exam. Acknowledge children and compliment them. Most parents will shut out an adult who ignores their children.

These simple things, though sometimes ignored, foster a positive relationship and gain the client's trust, after which they will more readily follow your recommendations.

Photo 1B: Radiography reveals an unerupted first premolar and a large dentigerous cyst. Removal of the unerupted tooth and the entire cyst is the only treatment.

Paradigm shift

Our main selling point for dental procedures until now has been convincing pet owners that the animals' teeth need to be cleaned. Many owners don't lift a pet's lips to observe the teeth. Why assume they would comply with a recommendation that implies a mere cosmetic benefit?

It's time for a paradigm shift – looking at a problem in a different way.

Oral malodor is present in the majority of pets with tartar and inflammation. This malodor results from the mercaptans, sulfides and other noxious substances produced by anaerobes that collect in periodontal pockets.

If there is odor, there has been a shift from the normal gram-positive aerobic environment to a gram-negative anaerobic one. Therefore periodontal infection is present.

Are pet owners more likely to agree to treat an infection in their pet's mouths or to clean their teeth?

Photo 1C: This patient was caught later in life. The cyst expanded to destroy the entire rostral mandible. These images are used to demonstrate the importance of radiographs when evaluating missing teeth.

We need to talk to them about the odor, the infection, the progression, the potential pain and systemic effects and leave the teeth-cleaning concept out of the discussion.

I usually tell pet owners that I don't care if the teeth are cleaned but I do care that the infection is resolved. Infection is resolved only mechanically, not medically. Removal of plaque, tartar, granulation tissue and diseased bone are the only resolution to treating periodontal disease effectively. So let's start talking about infection rather than cleaning, and you're likely to gain more client compliance.

Exam begins and ends in the mouth

In a memory test, the first and last items on a list usually are the most remembered. Use that concept in dealing with pet owners. The pet's mouth should be the first and the last thing you look at. A nationwide companion-animal study showed periodontal disease is the most diagnosed disease in dogs and cats of all ages. Therefore it is prudent to expect periodontal disease in your patients until proven otherwise.

Photo 2A: This patient has severe oral ulcers caused by chronic ulcerative paradental stomatitis (CUPS). These images demonstrate to clients what can be accomplished with treatment for this painful condition.

Use multiple senses

Draw the client into the examination through as many of the senses as possible.

When examining the mouth initially, a visible change in your calm expression to one of surprise, dread or disgust will relay non-verbally that what you see is not good.

Show the client the pet's mouth at this point. Ask if they have smelled their pet's breath and, if not, ask them to do so if the patient is not aggressive. Touch an inflamed area with a cotton-tipped applicator to detect pain. Have the client move a mobile tooth with a finger. Relay your deep concern with the oral disease and proceed, assuring the client that you will discuss the mouth after the rest of the exam.

Photo 2B: Full-mouth extractions were the only feasible option for this patient. This picture was taken six weeks after surgery. The ulcers are completely resolved and will not recur.

After you have engaged the senses and the entire exam is complete, you are ready to educate the client about their pet's oral disease verbally and visually, assuming there are no more serious issues that should be addressed first. Large, clear pictures, preferably on a computer screen or television, give the client a detailed view of the disease process. This supersedes the small, brief, mobile picture they had from looking into the pet's mouth, and provides a static model for you to explain the process.

Pictures of similar pathology are key

We often learn more effectively through comparisons. Showing the client a picture of the pet's mouth and comparing it to another pet's mouth with an equivalent stage of periodontal disease is a very effective teaching tool.

A digital picture of the patient's mouth can be taken in seconds by a technician with a digital camera on macro setting. The picture can then be transferred to a computer or television screen in the exam room. Pictures of patients with the corresponding radiographs of fractured teeth, feline resorptive lesions, stomatitis, missing teeth, etc., can then be used to explain the pathogenesis as it pertains to the client's pet. (Photos 1-4) (For a CD of images of common veterinary dental conditions that are specifically designed to increase compliance, please go to www.veterinarydentistry.net)

Photo 3A: This maxillary right fourth premolar has mild gingivitis and tartar.

Look at the example of the fractured tooth in Photos 4A and 4B. Clients may not realize that a fractured tooth will rapidly die and the pulp will become necrotic. Depending upon the location of the tooth, clinical signs may or may never become evident.

The classic presentation of sub-orbital swelling often is associated with an enamel fracture of the maxillary fourth premolar. Months or even years may pass after the fracture until the swelling appears.

However, fractures often produce no discernable clinical signs. Humans with fractured teeth and pulp exposure report significant pain and sensitivity. Pulp necrosis follows, resulting in more pain as the periapical tissue becomes inflamed and infected.

Why assume that our patients experience any less discomfort? Unfortunately they have few means to convey this pain and therefore it mostly goes unnoticed.

The preceding discussion should be relayed to the client, enhanced and clarified with pictures and radiographs of equivalent cases as shown in Photo 5. Client testimonials describing the difference in the pet's well-being before and after the procedure also are effective in explaining that pain often is manifested in subtle signs.

Photo 3B: A large area of bone loss is evident in the furcation between the roots. This demonstrates to clients the importance of full mouth radiography in detecting disease not otherwise visible.

Many clients attribute a pet's decreased activity to the aging process. ("I really thought he was just getting old.") Owners of pets with significant periodontal disease, fractures and stomatitis often return for post surgical rechecks to report that their pets feel noticeably better.

Compassion with a price

After all the time that you have spent with the client, they likely view you as a compassionate professional having their pet's best interest in mind. You have created an excellent environment for getting their commitment to proceed.

Now you attempt to present the cost estimate. Their opinion is immediately skewed to the negative. Why? It now seems to them that your compassion comes with a price tag. How can you avoid giving that impression?

Stay away from the monetary aspect. Train technicians and receptionists to give estimates, explaining in detail the importance of the procedures that you will perform.

Photo 4A: This cat has the distal portion of the mandibular right first molar missing.

Picture handouts ensure repeated exposure

It should be expected that many clients initially will not schedule an appointment for a recommended procedure.

But, again, pictures can help. As we demonstrated with the example of a fractured tooth in Photo 5, a four-part picture sheet is most effective and can be produced easily and quickly with basic computer software. The sheet is composed of a picture of the client's pet, a picture of the pet's oral disease, a picture of the image in your database that has a similar extent of pathology and a picture of that area on an X-ray.

Photo 4B: Radiographic images can create a dynamic impact on the client's perception of the severity of a condition such as this.

Once a client leaves without making an appointment, he or she is lost until the next visit. But at home they may repeatedly encounter the picture sheet that you have provided, reminding them that an appointment is needed. After all, their pet's picture is on the handout. They may cut out that one image and save it alone, but they wouldn't dream of disposing of it.

Follow-up phone calls by the doctor, reiterating the importance of treatment, is another good way to enhance client compliance.

Be creative

These obviously are not the only means by which a veterinary practice can increase compliance.

Establishing client trust, approaching the mouth first and last in the exam room, using multiple senses and providing pictures have proven very effective for our practice. They can benefit you as well.

Photo 5: This is an example of a handout easily produced with images of the pet and its pathology compared to another pet of similar pathology. Images are quickly inserted into the template created on a word processing file or other image software. A file with a collection of images of common dental conditions is invaluable for client education.

Be creative by making the dental exam fun and educational for the client, and your compliance will skyrocket. Your patients will be glad that you put forth the extra effort on their behalf.

Brett Beckman, DVM, FAVD, Dipl. AVDC practices referral dentistry at Affiliated Veterinary Specialists, Orlando, Fla.; Noah's Animal Hospitals in Indianapolis; and at Florida Veterinary Dentistry and Oral Surgery in Punta Gorda, Fla. He is president-elect of the American Veterinary Dental Society and board eligible in the American Academy of Pain Management.