Dental extractions: from anesthesia to send home (Proceedings)

There are very few states that allow technicians to legally do dental extractions. The American Veterinary Dental College has a published position statement outlining the dental tasks that can be performed by the veterinary technician.

Assisting for the extraction procedure includes laying out the instruments for the extraction, retraction of tissues, suction, irrigation, cutting suture, and after care. Why should veterinary technicians learn about extractions? Knowing how the extraction procedure is performed, assisting in the extraction procedure which also includes anesthesia and client education gives the best and most expeditious patient care.

Anesthesia and Monitoring Considerations

Once the patient has been cleared for surgery, IV catheterization and fluid therapy need to be prepared. An IV catheter provides a port for analgesics, anesthetics, emergency drugs and fluid therapy during the surgery. IV fluid therapy is essential for circulatory maintenance as dental extractions are often lengthy procedures. Perioperative IV antibiotics can be given at this time so that blood levels rise to the therapeutic levels. Perioperative antibiotics should be dosed according to the manufacturer's recommendations.

A plan for managing the pain of existing dental disease and the pain associated with the extraction procedure should be formulated. An anesthesia protocol that will be the safest for the patient starts with the client interview, physical exam and presurgical bloodwork. It is necessary to have flexibility with your drugs so that you can tailor the protocol to the needs of the patient.

The best results have been found when a multimodal analgesia plan is implemented preemptively, intraoperatively and postoperatively. Preemptive analgesia is the application of analgesia before any painful stimuli is introduced. Multimodal analgesia is done by using two or more analgesic drug classes simultaneously in order to inhibit nociception at different points along the pain pathway. Preemptive analgesia also decreases the intensity and the duration of postoperative pain. Depending on the severity of the extraction, most pain will occur in the first 24-72 hours postoperatively. The most commonly used drugs for multimodal analgesia in managing dental pain are regional anesthestics, opioids, NSAIDS, and α2 - receptor agonists. A good basic analgesic plan would be to include a opioid and α2 in the immediate pre and postoperative periods while the patient is still hospitalized.

Regional nerve blocks are given just prior to starting the surgical procedure and/or postoperatively. Regional nerve blocks are added to decrease peripheral and central sensitization and reduce anesthetic and postoperative analgesic requirements. Common sites for regional nerve blocks for dental extractions are the infraorbital, maxillary, mental, and mandibular inferior alveolar nerve block. Care must be taken with the mandibular nerve block, because inadvertent blocking of the lingual nerve can cause desensitization of the tongue, possibly causing self mutilation upon recovery. Keeping the needle close to the ventral bone of the mandible should avoid the lingual nerve. Care should also be taken with the infraorbital block to avoid inserting the needle too far into the infraorbital foramen and possibly causing ocular damage, especially in cats and brachycephalic dogs. Infiltrative blocks might be another option for regional analgesia. In infiltrative anesthesia, the periodontal ligament and surrounding tissues are directly injected. Infiltrative anesthesia works best where the cortical bone is thin such as around the maxillary teeth and the mandibular incisors. It also works well when only a few teeth need to be desensitized.

Once the patient has been induced, they must be have a cuffed and securely tied in endotracheal tube. The endotracheal tube serves two purposes: 1) it provides a secure airway in case of anesthetic emergency and 2) it prevents aspiration pneumonia caused by aerosolized debris and fluids that occur during the extraction procedure.

Place the patient on a warm, circulating water blanket to prevent hypothermia. Hypothermia is caused by inhalant anesthesia, which reduces the body's ability to respond to hypothermia. It is safer to maintain a core body temperature during anesthesia than to try to regain body heat after surgery. The body's trying to regain core temperature accompanied by severe shivering can increase myocardial activity and systemic hypoxia.

All dental patients should be monitored by a person other than the veterinarian and the assisting technician. Charting the anesthesia trends every 5-10 minutes should be done to avoid problems before they become serious. The monitoring procedure should be done using both hands on auscultation and palpation along with good quality monitoring equipment. Recommended monitoring equipment to have on hand are an ECG, Doppler blood pressure, capnometry, pulse oximetry, and end tidal CO2 level measurement. Apply lubricating ophthalmic ointment to the eyes often to prevent drying and protect from aerosolized fluids

Instrumentation

     • Periosteal Elevator – This instrument is used to elevate the mucoperiosteum in order to facilitate closing the extraction site and/or allow the removal of some of the alveolar bone in a surgical extraction. The larger elevators are used to elevate mucogingival and palatal surgical flaps. The blade comes in different shapes and sizes for use indifferent size patients and types of procedures. The blade has a flat side and a convex side. The flat side goes against the tooth surface while the convex side lies against the soft tissue to reduce tearing and trauma.

     • Dental Elevator – This instrument is used to stretch cut and tear the periodontal ligament which displaces the tooth root from the socket. The tips have a rounded scoop appearance with a sharp edge which may or may not be serrated. The concave side is placed along the tooth surface while the convex side lies between the tooth and the alveolar bone. The edges come in different sizes and shapes to facilitate different tooth sizes and extraction conditions.

     • Dental Luxators – This instrument looks like a dental elevator but has a slimmer and in some cases thinner tip design. Their thinner tip allows easier access to the periodontal ligament and is used just to cut the periodontal ligament around the tooth. If you use this instrument like an elevator, there is an increased chance of bending or breaking the tip.

     • Extraction Forceps - This instrument is used for gripping and removing the tooth after it has been loosened. The most common type is the small breed forceps which are nicely adapted to the conical shape of the animal tooth. It's small size and spring retraction allows less force to be placed on small teeth reducing the chance of crown fracture.

     • Root Tip Pick – This instrument is used to stretch and break the periodontal ligament, in order to retrieve a fractured root tip. They can be straight, right angled or left angled and the tips are narrow with two sharps sides and a pointed sharp tip. Gentle pressure must be used to avoid breaking the tip.

     • Root Tip Forceps – These instruments have fine pointed serrated tips and a 45 degree working angle that allows them to reach deep into the tooth socket to grasp and remove loosened root pieces.

     • Alveolar Bone Curette – This instrument is used to debride the alveolus after extraction. It has a scoop at the end and can be straight or angled with a long shank to reach deep into the alveolus.

     • Highspeed Handpiece – This instrument is used for sectioning teeth and removing alveolar bone for extractions. It has a water source using compressed air for cooling the bur. Highspeed handpieces run at 300,000 – 400,000 rpm.

     • Dental Burs - These fit on the highspeed handpiece to section the teeth and remove alveolar bone. For sectioning teeth, a crosscut fissure bur #701 or 701L is used. Round burs are used for slowly removing alveolar bone in a surgical extraction. Round bur sizes range from ¼ to 6 and the size you use depends on the size of the tooth you are working on. Generally, ¼ to 2 is good for cats, 1-3 for small dogs, and 4-6 for large dogs.

Ergonomics

Good surgical ergonomics need to be in place. Maintaining good posture and holding the instruments using the modified pen grasp will help reduce fatigue. Reduce exposure to aerosolized fluids and debris by wearing protective eyewear, mask and gloves. Having a good light source is essential as good visibility simplifies the procedure greatly.

Sterilization

Because the mouth is not a sterile field, sterilization is used not so much so that you have sterile instruments in a sterile field, but to kill the pathogens left by the previous patient. In the best case scenario, you should have sterilized instruments for each patient, but since most clinics are limited in that respect, you can use cold sterilization between patients, making sure to rinse the instruments thoroughly. At the end of the day, scrub, sharpen (if needed) and sterilize your instruments.

Sharpening and repair

Sharp instruments are necessary to expedite the dental procedure as well as protect the patient from the trauma that can be caused by a dull instrument. Test your instruments by testing them on a sharpening stick or a syringe case. If you have time to sharpen between patients, that's great, but most of the time we get it done when we can. There are many great videos on the market that teach sharpening techniques. These tapes are useful because you can sharpen along with the video. These videos are available through veterinary dental catalogs.

There are also mechanical honing systems available. These can also be used for sharpening other instruments in your hospital. They come with instructional videos and stabilizing guides so that your instruments are at the correct angle. The company that makes this unit is Rx Honing Machine – Mishawaka, IN.

Repairing broken instruments can save you money rather than constantly replacing them. Most major dental suppliers have instrument repair, check into prices and turnaround time. These places will also have a sharpening service as well if you want to periodically want to send in your instruments for sharpening.

Dental radiology

Preoperative dental radiographs are necessary. Knowledge of abnormal anatomy and pathology will allow the steps of the extraction to be planned. Postoperative radiographs to assess the extraction should also be taken.

Types of extractions

There are two basic extraction techniques: 1) closed or non surgical which involves simple luxation or elevation without the removal of alveolar bone, and 2) open or surgical which involves raising a mucoperiosteal flap to reveal alveolar bone. The flap is raised by making releasing incisions from the gingival margin to beyond the mucogingival line. Two-thirds of the root length of the alveolar bone is removed using a bur on a highspeed handpiece to expose the roots.5 The exposed roots allows the doctor to have a purchase point to place a dental elevator and start elevating the tooth. The open technique can be used on all teeth and is recommended if the tooth is not mobile.

When working with multi rooted teeth, it is best to section the tooth into single rooted sections using a taper fissure bur on a highspeed handpiece. In order to section a tooth, the gingival attachment to the tooth is cut exposing the furcation. The bur is inserted into the furcation and moved coronally cutting into the crown.

When using a closed or open extraction technique, suturing the gingiva over the defect is recommended. Suturing reduces postoperative pain. The suture material should be absorbable on a reverse cutting needle. 3-0 to 5-0 chromic gut is fine for most extractions and 3-0 to 5-0 poliglecaprone 25 where an extended healing time is needed such as an oronasal fistula repair.

Post-op patient care

Once the extraction procedure is finished and the patient has been extubated, the patient needs to be kept in a warm environment to prevent hypothermia. The patient needs to be monitored closely to prevent pawing at or rubbing the face. In some cases an e-collar may be appropriate. Analgesia needs must be addressed. Opioids and α2 agonists or injectable NSAIDS may be given immediately post-op.

Provide oral and written home care instructions individualized to the patient. When discharged from the hospital, injectable and oral NSAIDS plus a longer acting opioid may be used if a long convalescence is expected. Oral antibiotics are also indicated for 10-14 days. Alert the client to possible side effects such as bleeding coughing, nasal discharge, neurological signs, vomiting diarrhea, anorexia or signs of pain. Soft food should be fed either in the form of moistened hard food or canned food. Set up a recheck appointment for after the antibiotics have been taken.

Telephone the client the day after surgery to inquire about the patient's condition, ability to give the medication, the patient's tolerance of the medication, and answer any questions or concerns.

At the recheck appointment, check the sutured areas for signs of dehiscence or further infection. If the suture sites look healthy and healing is taking place, resume the patient's regular diet. Go over home care instructions again and revise if necessary. Schedule more recheck appointments until the disease or wound is controlled – monthly to every 3 months.

Conclusion

Extractions are a team effort. Clients must be given options for the optimal care and treatment available. If all members of the veterinary dental team strive to better the quality of dental care given by managing and maintaining the patients, pets can live longer healthier lives.

References

http://www.avdc.org/Dental_Health_Care_Providers.pdf - accessed December 16, 2005.

Carpenter RE, Marretta SM. Anesthetic management of the dental patient. In: Tranquilli WT, Grimm KA, Thurmon J, eds. Lumb and Jones' Veterinary Anesthesia 4th Ed. Philadelphia: Lippincott, Williams and Wilkins. In press.

Tranquilli WT, Lamont LA, Grimm KA. Pain terminology, physiology, recognition, and clinical strategies. In: Pain Management for the Small Animal Practitioner, 2nd Ed. Jackson: Teton New Media; 2004: pp2-12.

Gorrel C, Derbyshire S. Anaesthetic monitoring and postoperative care. In: Veterinary Dentistry for the Nurse and Technician. Edinburgh: Elsevier Butterworth Heinemann; 2005: pp19-24.

Gorrel C, Derbyshire S. Tooth extraction. In: Veterinary Dentistry for the Nurse and Technician. Edinburgh: Elsevier Butterworth Heinemann; 2005: pp119-129.

Holmstrom SE, Bellows J, Colmery B, Conway ML, Knutson K, Vitoux J. AAHA dental care guidelines for dogs and cats. In: J Am Anim Hosp Assoc; 2005, 41.