Why the 'dental' divides our profession

When Birdie the poodle needs a full dental with extractions but the client can't pay for it, how do you move forward? (oxilixo / stock.adobe.com)

Ms. Bertrand sat quietly on the chair in the exam room. Her aging poodle, Birdie, was perched on her lap. I could smell the dog's mouth the second I opened the door. There's just no mistaking the odor of putrid teeth tangled with hair and pus. Birdie was in for her “annual” checkup (the last one was about five years earlier).

I asked all the usual questions: “How's Birdie doing?” Good. “Any concerns?” Nope. “Any difficulty eating?” None.

I checked her chart-no change in weight since the last visit. By all accounts, Birdie was happy and healthy (excusing, of course, the cesspool that was her mouth). I lifted Birdie's lips and pointed out the dental disease to Ms. Bertrand. I painstakingly explained all the risks associated with the condition. I did all the things. I made all the recommendations.

I'd love to say that Ms. Bertrand consented to everything and that we got Birdie scheduled for a full dental with all the bells and whistles. I wish I could say that we immediately drew blood for her preop labs, ran the ECG, filled the antibiotic prescription and got the signed estimate for the dental radiographs, nerve blocks, cleaning, polishing and extractions. Yes, that would have been ideal.

But that's not what happened.

When I lifted the lip on Birdie's mouth, Ms. Bertrand was legitimately shocked. She had lived with the dog for 14 years, and at home Birdie was as energetic as ever. She never missed a meal (which mostly consisted of cheap canned dog food and an occasional scrambled egg). She barked at the mailman every day like clockwork. She still got excited when she saw the leash, and she chased the backyard squirrel up the tree every chance she got. In Ms. Bertrand's eyes, there was nothing wrong with Birdie.

When I explained all the hidden health risks of ignoring the dental disease, she nodded politely and said she understood, but she only had $40 left from her social security check each month, and that's why it had taken her so long to get Birdie in to begin with. In another three months, she might be able to afford a basic cleaning and a few extractions, but no more.

The options are not ideal

So now what? What do I do with Birdie's wretched mouth?

Option No. 1: Skip it. Do I ignore it and send the two of them out the door because there's no way she can afford the “standard of care” for veterinary dentistry? Do I turn my back on the ticking time bomb in Birdie's mouth and cross my fingers that she's not back in my exam room six months from now with complications?

Option No. 2: Treat to the gold standard. Do I move forward with all the recommended procedures, use all my expensive equipment and generate a $1,000 bill-knowing full well Ms. Bertrand will never be able to pay that? Spacing the procedure or charges out over several months would still generate the same overall expenses. We charge 18% annual percentage yield on unpaid balances (similar to many other alternative payment options). At $40 per month, it will take her three to four years to pay that off. Let's be real: Birdie and Ms. Bertrand may both be gone by then. If she does attempt payments and defaults, will I need to make the (poor) business decision to write it off? Or worse, send an elderly woman living on social security to collections? All these scenarios seem likely to end in a social media firestorm where I'm accused of being a greedy, profit-driven, heartless veterinarian.

Option No. 3: Treat what I can. Do I instead perform the dental procedure taught to me by my mentors in rural mixed practice? The kind where I check basic blood parameters and use my stethoscope, eyes and ears for anesthesia monitoring? Where I remove the teeth that are visibly rotting and falling out, using fingers and elevators to make an educated guess about the viability of tooth roots? Where I employ only minimal force for extractions, then clean, polish and send the dog home on antibiotics, anti-inflammatories and education about at-home care? Do I perform a dental Ms. Bertrand can afford (and will need several months to pay), knowing that if I do, I risk being accused of malpractice by my colleagues? And if I post about it in an online veterinary group, will I be vilified for performing basic techniques?

I ponder my choices and ultimately choose the one that gets Birdie's mouth cleaned up the fastest: option 3, where I do everything I can while trying to respect Ms. Bertrand's budget. I explain all the risks and outcomes and do what I can to get Birdie home barking at the mailman as quickly as possible.

I refuse to use the ‘noncompliant' label

Want to know what I won't do?

I won't judge Ms. Bertrand for declining procedures and products she can't afford. I won't condemn her or label her noncompliant. I won't disrespect her because she's not able to spend the equivalent of more than a year's worth of Birdie's food for a top-of-the-line dental procedure.

Also, I probably won't bring up the visit at the next dental CE I attend-and I won't lose any sleep over that. I'll sit politely in the middle of the room and doodle in my notepad as it's implied that I'm being cruel to dogs like Birdie and will likely get sued by people like Ms. Bertrand.

The reality is that my practice is full of Birdies and Ms. Bertrands, and I'm a better veterinarian because of it. Clients and cases like these continually push me to trust my instincts to be an excellent communicator. They teach me just how far $200 can stretch diagnostically. They're the reason I have my Five-Minute Consult books memorized. I have them to thank for sharpening my common “sense-ability.”

All that said, they're also the reason I have a love/hate relationship with this common oral health procedure and all the conversation and marketing that goes with it in our profession.

Dr. Melissa Detweiler is an associate veterinarian at Bern-Sabetha Veterinary Clinic in Sebetha, Kansas. In her free time, she enjoys reading, being out in the yard during the warm months, running, fishing, following K-State sports and, above all, spending time with her husband, children and their Rottweiler mix, Lucy.