Questions from the dental trenches: The practical side of veterinary dentistry

Over the years I've given a lot of lectures on veterinary dentistry at continuing education conferences and sponsored symposia. And I've gotten to where I can almost perfectly predict what the audience's top questions will be at the end of my sessions.

I'm assuming that you might have some of these same questions, so I'm kicking off a three-part series of "dental FAQs" to provide answers to some of the more practical concerns when it comes to veterinary dentistry. If you have a question you'd like to see answered in the next two installments, send an e-mail to dvmnews@advanstar.com.

Q. On dental day, we perform six to eight prophys, but we would like to perform more. How do we bring in more patients?

A. The first thing to realize is that there is practically no such thing as a "routine prophy." Patients that have been anesthetized for a "prophy" have visible calculus and gingivitis or they would likely not have had the "prophy" scheduled to begin with. Cleaning without evaluating the patient radiographically is of little to no benefit. And with radiographs, almost all of those "30-minute prophys" are really 60- to 120-minute or longer oral surgical procedures involving periodontal regenerative procedures, plus or minus surgical flaps and extractions (Figure 1). The problem is not the number of patients being low; the problem is not doing a thorough job on the patients we have.

>>> Figure 1: This patient had a dental cleaning a month before presentation but still exhibited odor and oral discomfort. Radiography revealed multiple areas of marked periodontal bone destruction necessitating multiple extractions.

Q. Our clients will not opt for expensive dental services. It is hard enough to get them to agree to a prophy. How can we make sure they agree to needed dental work?

A. Vilfredo Pareto, an Italian engineer working in France in the late 1800s noticed that 80 percent of the land was owned by 20 percent of the population. From that observation grew the Pareto principle, or the "80-20 rule." It holds true for a multitude of real-life examples, veterinary practice dynamics being one of them.

You are correct in assuming that most of your clients will not take your recommendations regarding any high-end service. Eighty percent will say no to plating for a limb fracture, a complete workup for an acute vomiting patient, a cardiac evaluation, an ultrasonographic examination—and the list goes on. It is the 20 percent who will opt for dental radiography and will pay for the therapy required uncovered by this invaluable standard of care tool that you should focus your efforts on.

Q. We have dental radiographic equipment, but it would take us 45 minutes to an hour to take full-mouth radiographs in a large dog. How can we become more efficient?

A. Many practices feel the same way. The answer is practice. Practice on cadaver head specimens, not skulls. Cadaver specimens are the closest equivalent to a live patient and are the only way to become proficient before providing this service to a live anesthetized patient. Proper guidance in positioning and software template setup is essential and can be obtained at www.veterinarydentistry.net/x-ray-book. Reachable full-mouth radiographic time goals are 20 minutes or less on a large dog and eight minutes or less on a cat or small dog.

Q. We have a technician who is good at taking radiographs, but the practice manager or owner is always trying to get us to hurry to finish one prophy so that we can get to the next one to meet the schedule for the day. How can we find the right balance?

A. If you have to ask that question, the entire dental service needs to be restructured and the entire staff (other than the technician who is taking the radiographs) needs proper continuing education. Complete evaluation of each and every patient for oral disease requires the production of a full-mouth radiographic survey, proper interpretation by a veterinarian, preemptive client education by technicians and veterinarians, timely estimate generation by the receptionist and proper treatment by a veterinarian trained in dental radiographic interpretation and surgical extractions. Surgical extractions should be the most commonly performed dental procedure if the veterinarian is properly trained in interpretation and therapy. Courses for veterinarians and technicians can be viewed at www.veterinarydentistry.net.

Q. We have four veterinarians in our practice, and three of them will see dentistry cases. One is very knowledgeable, but the other two miss many things that the knowledgeable one would correctly treat. How can we make sure all patients get top-notch care?

A. This is an extremely popular question. The answer involves putting yourself in a client's shoes. Who would you rather have evaluating and treating your pet for oral disease? The practice must come to this realization and invest in further continuing education for the veterinarian who shows the most interest, knowledge and skill in dentistry. Deem that individual the sole curator of the dental suite, performing all radiographic interpretation and treatment. That person may become the busiest in the practice, significantly adding to the revenue per dental case by applying his or her superior knowledge and skill. Most importantly, the patients will be the ultimate winners.

>>> Figure 2: This cat demonstrated no obvious signs of pain at home. The referring veterinarian noted the painful stomatitis and referred this cat for proper care to a veterinary dentist for full-mouth extractions.

Q. What do you say to a client who doesn't think a pet needs a dental cleaning and radiographic evaluation because it is not showing signs of pain?

A. This is a very common owner objection. Here are several suggestions:

1. Do not allow owners to voice the objection in the first place. Preempt questions by telling clients that most dentistry patients do not present with signs of pain. Relay to the pet guardian that most of the time we only know that the patient was painful at the recheck examination. If a patient with periodontal disease that requires extractions has undergone appropriate surgical correction with flaps, diseased bone and tissue removal, extractions and closure, the owner will relay any number of positive behavioral changes that he or she has seen in the pet since the surgery. Only then do clients realize that their pets were in pain. Some pet guardians feel very guilty at this stage, thinking that their pets were just getting older and lamenting on how they let this go.

>>> Figure 3: This mixed-breed dog presented for oral malodor, not pain. A spring had lodged between the teeth and had resulted in bone necrosis and the odor.

2. Show them images of patients that came in for problems other than pain but had obviously painful oral conditions (Figures 2 and 3). Images of nonoral painful conditions are also effective (Figure 4).

>>> Figure 4: This geriatric dog presented wagging its tail but was non-weightbearing on its limb. The owner's perception was that the dog was not in pain. However, it turns out that the patient had osteosarcoma, which is a severely painful condition.

3. As veterinarians and technicians, we often observe pain in our patients during oral examinations while probing painful regions and experiencing a pain reflex in the form of a sharp jaw movement upon contact. Relay this to the pet guardians verbally, or record the event and present it during the consultation.

4. Nonverbal patients cannot demonstrate pain easily and often mask it, continuing to eat, play, go for walks and so on. Pet guardians should be aware of this ability to mask pain.

Dr. Brett Beckman lectures internationally on veterinary dentistry and sees patients at Affiliated Veterinary Specialists, Orlando, Fla.; Florida Veterinary Dentistry and Oral Surgery, Punta Gorda, Fla.; Animal Emergency Center of Sandy Springs, Atlanta; and Dallas Veterinary Dentistry and Oral Surgery, Dallas. Find out more at www.veterinarydentistry.net.