Feeling the bite of the economic downturn?

The veterinary profession is undergoing unprecedented change due to a variety of factors, including global economic downturn, restricted credit availability, a sagging real-estate market, rising costs of education and the changing veterinary demographic profile.

Veterinary clients budgeting their discretionary income are seeking high-value services. Veterinary dentistry is a high-value service when provided optimally. It improves the lives of companion animals and makes clients smile, eager to spread the news about the high value services they received.

A dental-service focus may be a good strategy at this time.

It is time to stop scheduling "dentals" and focus instead on diagnosing dental problems and performing meaningful dental treatments. Explaining the value of dental services helps elevate client perception of those services. Clients are more likely to spend their discretionary dollars on a comprehensive oral assessment and treatment than on "just a dental."

Dental services that focus on both the client's priorities and the patient's teeth are particularly rewarding and are perceived as high value when clients understand the underlying problems and participate in decision-making on treatment.

Veterinarians need to educate staff members and clients about the importance of dental problems and the impact these problems have on a patient's quality of life.

Periodontal disease

It is the most prevalent of all diseases in pets (Photo 1).

Photo 1: This radiograph demonstrates endodontic and periodontal pathology.

If every employee in your practice understands the prevalence of periodontal disease and the potential consequences, your dental services are perceived as a high-value diagnostic and treatment service rather than a grooming procedure. This perception is shared by your staff members and your clients. Every client will appreciate being informed about periodontal disease and your dental department will no longer be viewed as a "teeth-cleaning service" similar to a car wash.

Photo 2: Periodontal defect.

Periodontal disease is an infectious, inflammatory and destructive process. Most cats and dogs over 4 years old have it. It can be particularly painful, but we often fail to recognize pain in companion animals.

Failure to recognize periodontal disease can result in adverse consequences for animals. Periodontal pathogens may spread through the bloodstream and colonize in other organs. Additionally, uncontrolled periodontal disease can affect glycemic control in diabetic patients. Failure to regulate the diabetic patient can result in further problems.

Antibiotic therapy is inadequate as a monotherapy for periodontal disease and should never be used for prevention or management of chronic oral disease. Indiscriminate antibiotic use can cause problems. Professional care followed by home care provides optimal management (link: www.mypetsdentist.com/site/view/114726_TeethCleaning.pml) of periodontal disease.

Pain management is best accomplished through appropriate diagnosis, treatment planning and meticulous performance of treatments. While pharmaceutical pain management can be an important component of treatment, it should not be used as a sole therapy for dental problems.

Educating clients

Client participation in pet oral hygiene via appropriate home care along with periodic veterinary evaluation (re-checks) improves compliance with all dental-service and product recommendations. Clients then further appreciate the value of these services. They are impressed when every staff member is well-educated about periodontal disease. Discussion between clients and staff members emphasizes the importance of professional dental care followed by appropriate home care and the use of Veterinary Oral Health Council (VOHC) approved (www.VOHC.org) products.

Staff members can demonstrate useful techniques for interacting with pets to improve the client's ability to brush the teeth effectively. Slow, gentle technique with a calm voice is helpful (www.mypetsdentist.com/site/view/114728_TeethBrushing.pml).

Photo 3: Chronic ulcerative para-dental syndrome (CUPS).

Chronic ulcerative paradental syndrome (CUPS) and feline stomatitis are painful (Photos 3 and 4).

Photo 4: Feline stomatitis.

Many patients with chronic dental disease have substantial oral pain. Teeth brushing in these pets often exacerbates pain.

Attempting to give oral medications such as antibiotics or analgesics may contribute to client frustration and promote a feeling of hopelessness. Home care ceases and the pets suffer even more.

Concerns about a pet's future and quality of life should be an immediate priority. For these severe cases, clients particularly appreciate referrals to specialists for advanced diagnostics and extensive treatments. This is especially true for dogs with CUPS or cats with stomatitis. Education is fundamental to providing a high-value service for these chronic and devastating conditions.

CUPS and stomatitis patients need diagnostic dental radiographs with periodontal probing. In cases where all four dental arches are involved, biopsies and bacterial cultures are rarely of value. The author encourages full-mouth dental extraction for most of these patients; however, each case is evaluated individually. Clients do not perceive high value from these oral surgery services if the problem continues after surgery. Therefore accurate diagnosis and treatment planning is critical. Accurate diagnosis helps establish the long-term prognosis and helps communicate reasonable expectations to owners.

Clients who are referred to dental specialists frequently perceive their primary-care veterinarian as a partner and advocate for their pet's overall health, and may even brag to friends about this. Sending patients to specialists frequently results in a stronger bond because clients see how much you care.

Fractured teeth

Have you ever experienced a chipped or fractured tooth (Photos 5-7)? With or without pulp exposure, they are likely to be painful. Because the anatomy, physiology and neurology of companion animals are similar to those in humans, it is reasonable to assume fractured teeth hurt. Veterinarians know that acutely exposed dentin is sensitive. Dentin tubules contain nerve fibers that communicate with the pulp.

Photo 5: Fractured left upper-fourth premolar tooth; near pulp exposure.

Clients expect veterinarians to recognize and make appropriate treatment recommendations for fractured teeth. Suggestions to wait and see what happens with these teeth is never viewed as adequate informed consent. It is more likely that something bad will develop with fractured teeth than something good. In such cases "wait and see" can be perceived as a misdiagnosis and loss of the client, their family and friends. Fractured teeth with pulp exposure should be treated by dental extraction or with endodontic therapy.

Photo 6: Radiograph of the fractured left upper-fourth premolar.

Clients come to their veterinarian for advice. If fractured teeth have been identified, recommendations for prevention of fractured teeth also are appreciated. Fractured canine and incisor teeth are likely to occur as a result of trauma from rough play, or accidents with baseball bats or golf clubs. More gentle forms of interaction may help avoid dental fractures.

Photo 7: Dental radiograph of left upper-fourth premolar fracture. Note the pulp is exposed.

Pets with fractured premolars or molar teeth are more likely to sustain these injuries from occlusal trauma. Recommendations to avoid hard chewing objects can help prevent fractured teeth.

Animals with separation anxiety often fracture teeth when confined to cages. Providing referral options to a behaviorist and being selective with confinement can help reduce dental fractures.

Discolored teeth should be thoroughly evaluated (Photo 8).

Photo 8: Discolored lower molar.

Tooth color is dependent on age, dental care, diet, dental abrasion and attrition as well as other factors. Blunt-force trauma is a frequent cause of tooth discoloration.

Trauma causes pulpal bleeding and results in blood cells entering the dentinal tubules. Once there, the blood oxidizes, causing discoloration. Teeth exhibiting coloration different from adjacent teeth should be evaluated individually.

Purple, tan or black teeth are likely to be non-vital (dead) and become a substrate for bacterial colonization and systemic spread of microorganisms.

Non-vital teeth may be treated by dental extraction or with endodontic therapy.

Many clients view their pets as family members, and few of them would choose to have their own teeth extracted. They appreciate hearing all the options.

Financial decisions on pet health care are best made by clients who have the facts regarding all diagnosis, prognosis and treatment options.

Tooth resorption

This, too, is a potential source of pain in companion animals (Photo 9).

Photo 9: Probing tooth with tooth resorption.

Tooth resorption, which occurs in both cats and dogs, is a progressive disease process that involves both crown and root structures. These patients tend to be in pain if dental resorption is present within the gingival sulcus or on the crown. Diagnosis involves observation, periodontal probing and dental radiography. If tooth resorption is evident on observation or by dental probing, full-mouth dental radiography is necessary.

Restoration of teeth with dental resorption is not beneficial. Extraction is the best treatment; however, the procedure is not simple. Dental radiographs are needed to confirm complete extraction, which is recommended when possible to minimize long-term inflammation and pain.

Oral masses should be evaluated, diagnosed and appropriately treated (Photos 10-11).

Photo 10: Extraoral view of an oral tumor.

Common in cats and dogs, they may develop from chronic periodontal disease, occlusal trauma or they may be benign or malignant oral tumors. Biopsy and dental radiographs are fundamental first steps in diagnosis.

Photo 11: Dental radiograph of a case with osteosarcoma.

Most companion animals with oral tumors experience pain and discomfort. As the tumors grow, bleeding, malodor and difficulty with chewing cause increasing discomfort. Many oral tumors are amenable to extraction. Their removal provides some degree of comfort for animals.

Dental radiography is important in determining the extent of tissue involvement and in planning surgical margins. Histopathology is important in establishing a firm diagnosis for follow-up treatment.

For benign tumors, surgery often is curative. For malignant tumors, however, adjuvant radiation or chemotherapy may be indicated. The author consults directly with a veterinary oncologist in these cases to provide optimal case management.

Clients are worried when an oral tumor is identified. Veterinarians working together with veterinary dentists, oncologists and surgeons can help clients make important decisions.

A multidisciplinary approach to pet care is rewarding for all involved.

Summary

Your dental department can be part of the solution to economic pressures on your general practice. Because clients view companion animals as family members, they will carefully choose services of high value. The term "dental" does not help with the perception of value in dental and oral surgery services. Value is perceived best when clients receive accurate diagnosis, prognosis and treatment.

Respecting client priorities by including them in oral-care decisions is critical. Clients appreciate good advice and optimal care. Veterinarians find that a multidisciplinary approach to pet health care bonds clients to general practices. Working together is a winning strategy, regardless of the economy.

Dr. Kressin operates the Animal Dental Center in Oshkosh, Wis. He is a diplomate of the American Veterinary Dental College and provides a conforming residency recognized by the American Veterinary Dental College.