Enamel pearls and tooth fairies: Making dentistry profitable (Proceedings)

The creation of a successful dental profit center requires the following: creating a dental team and establishing its oral disease philosophy, educating all the team members and finally marketing the product albeit educating the clients in order to accept the clinic's treatment recommendations.

Philosophy, Treatment Rationale and Stumbling Blocks

The dental team's philosophy is that the oral cavity must be examined routinely as part of all physical examinations. Since the oral cavity is the gateway to either health or hell, many of the animal's other physical ailments can either be caused by or negatively impacted by a diseased mouth. Dental disease can be chronic or acute, but in all situations the animal often does not show early signs to the owner. Appetite during these initial stages is often not visibly affected therefore the client is lulled into a false sense that their pet's enjoying good health. The unfortunate circumstance is that all these oral lesions will progressively deteriorate by ignorance of their existence or worse by the client's or practitioner's neglect. We therefore must evaluate thoroughly at every opportunity the mouth and be proactive in our oral recommendations.

The veterinarians and staff reception and technicians, must all believe in the importance of good oral health for every patient. This translates that the practice goal of quality of care must include the oral cavity as part of the other body systems. The general examination therefore must include an in depth evaluation of the hard and soft tissue structures of the mouth. Veterinarians must schedule more appointment time for client education by their staff and or themselves to examine the mouth, explain oral problems and the necessary treatment steps.

The seriousness of dental disease must be stressed to the client in order for them to be made aware that if left untreated that the animal's general health will be impaired. Obvious early or late signs of gingivitis, fractured teeth oral masses are very self explanatory when shown to the client. Treatment does not require a "hard sell" since client's understanding of oral maladies equate with their own dental problems. They therefore have a much better first-hand understanding of the pain associated with bad teeth then let's say pancreatic disease. Every effort therefore should be made to make the connection between human oral problems and their pet's oral issues. Stress that animal's have the same nerve sensitivity that they have. Redness and swelling in our mouths are associated with pain and that since the animal can't easily show their discomfort that the owners can't assume because their pets eat that they are comfortable doing so.

The positive benefits of a healthy mouth need to be reiterated and emphasized to the client. Not only will their special friends be more pleasant to live with when they are not exhibiting halitosis, but also they will be happier without chronic pain issues. This all translates into a longer life expectancy with fewer other medical problems like kidney liver or heart disease.

A client's acceptance of your team's recommendation depends on our salesmanship of the product. We are at our best when we are convinced of the necessity for the service. That means if we come across to the client as a dental cleaning can be done versus should be done, it is immediately perceived by the client as "let's wait and see until it becomes bad enough to treat"! Unfortunately this is truly malpractice. Watching a condition, that is reversible or treatable, become serious without recommending treatment, is incomprehensible.

Veterinarian's lack of dental progressiveness stems often from their uncomfortability in the oral cavity. This then translates into excuses on not being orally proactive. The doctors might list time constraints as an excuse not to do dental cleanings. "Our busy surgical schedule does not leave adequate time to do dental cleanings". This translates into "we are doing a host of non-profitable spays and neuters which we feel are more worthy veterinary medical activities".

The truth of the matter is that no practice has become economically thriving by doing these services and we are therefore missing the economic boat of dentistry. A proper dental prophylaxis is earning clinics around the country from $250-$400 per patient. Can we afford to not book 2-4 of these procedures per day if it would mean hiring additionally two dedicated dental technicians?? Not only is it profitable but GOOD MEDICINE!

Another excuse is "we are concerned about our client's objections to the procedure because of anesthetic safety issues for so to speak elective procedures". The fallacy of this thought process is that cleanings are often absolute medical necessities because the pets are already in the disease state. Spays and neuters, on the other hand, can be considered elective because the animal is healthy. Why do we advocate so strongly these anesthetic procedures? Clients are more likely to leave clinics due to their veterinarian's lack of proactiveness towards their pet's oral disease. Anesthesia and its safety need to be discussed with the client. Clinics need to have the proper anesthetic monitoring safeguards to ensure minimal patient risks. The client needs to be informed that neglecting the initial oral disease will put their pets in a greater anesthetic risk category as the disease progresses and causes more problems later.

Veterinarians are often concerned about client price objections to doing the procedure. This is especially apparent when they themselves do not believe in the value of a healthy mouth. Receptionists when dealing with dentistry price shoppers need to be stating that the fee is dependent on the degree of disease that is present. That is why it is important to have a doctor evaluate the animal before any estimate is given. Not only to give a more accurate estimate but also to assess potentially other oral problems unbeknownst to the client. Just like no two people have the same problems in their mouths; pets can have a multitude of problems present. A realistic estimate can only be given therefore when each and every tooth is evaluated.

So in order to feel more comfortable in our patient's oral health recommendations it is very important to understand what is normal in the mouth, what pathology can be expected and what our treatment plan should contain. This boils down to education, education and education!!

Technicians as Dental Care Educators

When asked how a clinic starts to implement a dental program into its regular operations, the answer is total staff involvement at the time the pet is first presented as a puppy or a kitten. Dental education of the exam room technicians allows for the initial client education into the care of their new pets teeth and oral cavity and discussion of any problems. Technicians not only need to know how to clean teeth but their understanding of normal oral anatomy, tooth development and eruption times and the associated developmental or acquired pathology helps them market with conviction dental services. Since they are the first to come in contact with the client, they often will set the stage for the client's acceptance of a dental treatment for their pet.

On the first visit the technician informs the clients of safe chew toys that can be used with their pets. They need to stress that hard play objects should always be avoided since animal's teeth are weaker than our own and especially in young animals they are more likely to be damaged by inappropriate hard chew toys. Games like "Tug of war" should not be promoted. Not only does it incite dominance behavior but it also has a high risk of damaging the deciduous and as well the young erupting adult teeth. Luxation and/or avulsion of teeth and rostral mandibles, is more common due to the weak mineralization of the young jaw bones. Catching Frisbees in midair can also lead to either tooth fractures or devitalization of teeth which either become pink or grey in color. These are teeth that need the veterinarian's immediate attention, since a dead tooth's necrotic pulp will drain into the surrounding supporting bone and cause it to weaken and eventually fracture. Endodontic therapy or exodontics is the treatments of choice.

Clients need to be informed that there is no pet food presently available which will eliminate the need for daily home dental care and periodic cleanings by their veterinary team. Like our own mouth our pet's mouths require daily brushing. The mouth is the gateway to either health or disease and the number one disease affecting small animals is periodontal disease. This can start as early as 7-9 months soon after the adult teeth erupt. Young cats that exhibit significant gingival and bone recession or Juvenile Periodontal disease will eventually loose their teeth despite the owner's best efforts at home hygiene. The client needs to be therefore informed of this fact early on during the veterinarians care. They also should consider interventive extractions which will reduce the course of the disease and substantially reduce the animal's pain and the clients nursing care. Often after a total mouth extraction, the gingiva heals rapidly and the pets will return to a normal pain free life and even be able to eat hard food. The veterinarian needs to be very proactive in this situation.

In the normal population of our patients, getting the young animals use to the idea of having their mouth played with should be shown by the technicians in the exam room. They demonstrate that after massaging the animal's muzzle the pet is rewarded with treats which develop the pet's trust. Once they readily accept the hand touching, a rubber finger brush and some animal toothpaste is gently applied to the outside surface of the teeth. At this stage the owner is given a sample paste and allowed to brush their animal's teeth with the technician's supervision. Since most pastes are good tasting the pet will readily lap it up which will promote the client's compliance. The pet should be sent home with a tooth brushing kit and the owner informed that in 6 months the technician will set up a brief dental exam to monitor for any tartar accumulation that might require a professional tooth cleaning.

Veterinarians as Dental Care Givers

The doctor should always initiate their physical exams with a good oral history. They must question the client in regards to their pet's behavior and eating and be on the lookout for warning signs indicating oral disease. This will help pin point a general malaises and weight loss or inactivity to one which can involve the mouth.

The following interrogatories are appropriate for a good dental history taking: Is the pet....acting hungry but being reluctant to eat and vocalizing ....only eating wet food when in the past they were avid dry food eaters...dropping food out of their mouth when eating....appearing to gulp their food with a ravenous appetite... ... rubbing or pawing at their face either during eating or immediately afterwards.... refusing to play with their toys....reluctant to having their face stroked...exhibiting a sudden or a slow onset of halitosis...salivation or drooling....sneezing and having nasal discharge associated with drinking or eating...showing facial swelling under the eye behind the nasal philtrum or under the jaws...exhibiting red swollen gums or loose teeth.

After the history taking the animal needs to be observed for changes in asymmetry of the muzzle or head. Unilateral swellings should be noted, facial hair discolorations, skin lesions in the head area, nasal or ocular discharge all must have a high index of suspicion for oral disease until proven differently. The doctor must examine the animal for the presence of all its teeth. This is an important part of not only prebreeding exams but also during a young dogs development. Absent teeth can have genetic causes or be acquired as in the case of crowns that are traumatically fractured. Since the root is anchored in and protected by bone, the crown confronted with shearing forces snaps off at the gingival level. The gums quickly overgrow the remaining roots. Contrary to popular thought, often the remaining roots do not resorb but create a foreign body reaction in the bone. This leads to osteolysis and draining soft tissue tracts. These roots, if present, need to be surgically extracted, the alveolus curetted and the gingival flap closed over the extraction site.

The veterinarian needs to note in their physical exam, in addition to missing teeth, any changes of the form of the teeth. Teeth can be damaged in their shape by chronic repetitive behavioral vice. The most common of these is "cage biting" or fence chewing. Animals that are most likely to engage in this behavior and exhibit enamel abrasion on the distal or caudal surface of the anterior teeth are sporting breeds and working dogs. Unless the behavior or the environment is altered, continued wear of the tooth will cause the loss of supportive tooth structure and will lead to subsequent fracture of the teeth. Usually the teeth with missing enamel become discolored on their distal surfaces. The veterinarian needs to be proactive at this time in talking with the client as to alternatives to prevent further damage. In addition to behavioral modification, the teeth can be bonded with 3/4 metal crowns which cover only the damaged area with protective metal and reduce further wear.

After the teeth numbers and form have been evaluated, the soft tissue of the lips and the oral mucosa and gingiva need to be evaluated. In addition to inflammatory periodontal disease which causes bleeding redness and swelling, other diseases can affect young animals. Swellings need to be evaluated for color, location (unilateral vs. bilateral) size, and consistency. Congenital, infectious, traumatic and neoplastic conditions need to be ruled out as possible causes of these swellings. Evaluate the age of the animal when the lesion developed. Are there any associated oral problems that could be contributing factors? Form a working diagnosis and a possible rule out list. Combining a thorough history and physical exam followed by oral diagnostics (radiography, biopsy and culture sensitivity) will narrow down the etiology and present a viable treatment plan.

The Secret of Dental Marketing

The key to developing an effective dental program is the education of all staff members. The receptionists need to be incorporated into the team by involving them in the patient care. Having them see first hand, what types of dental problems exist and how the hospital team cares for them, will allow the receptionist to not only book oral appointments with authority, but also reiterate the importance of home care, dental products and the veterinarians release instructions. The exam room technician and treatment technicians will educate the clients first hand on what was done to their patients. They will also be involved and carry out the preliminary oral exam, charting dental radiography and cleaning. The veterinarian will be the quarterback of the team. Their enthusiasm and concern for good oral health in all pets during their physical exams will be perceived by the client. The proactive dental team will educate the client to their pet's dental health or disease and how to appropriately care for them. The appropriate dental therapy, irregardless of fee, will be accepted by the client just as all other sincere hospital treatment plans.