www.AnimalDentistrySolutions.com
Centers for Oral Care
Veterinary Dentistry
2nd Opinion
Animal Dentistry Solutions
No. 8---25Nov2016
A BLOG by DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
1-800-838-3368
The
Road to Excellence
Student
and Teacher
The Pathway to New Millennium Optimal Oral Care
Lao Tzu comments: “When the
student is ready the teacher will appear. When the student is truly ready...
The teacher will disappear!”
I
have been blessed to take on the role of student and teacher through my last
twenty years in companion animal oral care. The Lao Tzu words of wisdom reflect
my personal growth in a field that I love.
How
many of us forget those that are responsible for the person that we are
today. I would like to reflect on some
special mentors of mine. Dr. Robert
Wiggs, the father of modern veterinary dentistry, answered hundreds of
E-communications; taught me in wet labs; and counseled me at national meetings. I was able to visit him in his practice in
Dallas and he welcomed me as he would a family friend. He was always there with a smile and always
had the correct answer. He taught me now
to teach with humility, kindness, and exactitude.
Dr.
Tom Mulligan presented to me the initial AAHA courses in endodontics. He was a tough teacher and expected maximum
from his students. I have become like
Tom in many ways. I can never become Tom
because there will be only one Tom Mulligan.
Once you got to know Tom he was the most kind and generous person you
could ever meet. Bob and Tom have left
this world but their legacy and contributions will last a life time through
those that they have mentored who, today, continue to teach the next generation
of animal dentists.
Dr.
Peter Emily guided me through many of the initial courses in veterinary
dentistry in which I participated as student.
Dr. Emily is both a human dentist and an animal dentist. He gave of himself to all of his students and he
always was there to help. I would
describe Peter as selfless and positive in all of his actions. If it were not for Peter I would not be
involved in zoo dentistry and helping members of the Animal Kingdom that many
will never have the ability to treat.
Zoo and wildlife dentistry is an awesome responsibility and I take my
commitment to this area quite seriously.
Thank you Pete for always being there.
The
Half-Life of Knowledge Shortens By the Month
William F. Wathen, DMD,
former Editor of in chief of the Journal of the American Dental Association and
Adjunct Professor in the Department of General Dentistry at Texas A&M
Baylor College of Dentistry states the following:
“It has been said that
only wet newborns embrace change, but change is ever present in our lives and
our practices. The half life of
knowledge shortens by the month; and new equipment, instruments, and materials
are introduced regularly. The ability to
embrace change—and use it plays a critical role in our happiness and satisfaction
as clinicians……….two of life’s healthiest habits are to be persistently inquisitive and
remain open to careful evaluation of new or modified ideas.”
Along with this change and
understanding of new or modified ideas comes and even greater responsibility to
understand our commitment to “safe anesthesia journeys!” Veterinary anesthesia is no different than human
anesthesia. Risk is present but the risk
factors are minimal when the highest standards of anesthesia are met and
incorporated into all veterinary practices.
The pets that we care for
are the children of our clients and our approach to anesthesia must incorporate
excellent pre-anesthesia testing; involvement of specialists in
cardio-pulmonary exams of geriatric patients; and state of the art monitoring
of all patients under Inhalant General Inhalation anesthesia. We should not be performing oral care with
chemical and non-reversible intravenous and intramuscular anesthesia
agents. Even in human dentistry, these
agents are only used for very short procedures and coupled with local or
regional anesthesia blocks. These human
sedation techniques are not applicable to the Complete Periodontal Prophylaxis;
Supportive Periodontal Care; Comprehensive Oral Health Care and Assessment; and
advanced oral care procedures by animal dentists.
Dental Scaling Without Anesthesia-American
Veterinary Dental College
In the
United States and Canada, only licensed veterinarians can practice veterinary
medicine. Veterinary medicine includes veterinary surgery, medicine and
dentistry. Anyone providing dental services other than a licensed veterinarian,
or a supervised and trained veterinary technician, is practicing veterinary
medicine without a license and is subject to criminal charges.
This page
addresses dental scaling procedures performed on pets without anesthesia, often
by individuals untrained in veterinary dental techniques. Although the term
Anesthesia-Free Dentistry has been used in this context, AVDC prefers to use
the more accurate term Non-Professional Dental Scaling (NPDS) to describe this
combination.
Owners of
pets naturally are concerned when anesthesia is
required for their pet. However, performing NPDS on an unanesthetized pet is
inappropriate for the following reasons:
1. Dental
tartar is firmly adhered to the surface of the teeth. Scaling to remove tartar
is accomplished using ultrasonic and sonic power scalers, plus hand instruments
that must have a sharp working edge to be used effectively. Even slight head
movement by the patient could result in injury to the oral tissues of the
patient, and the operator may be bitten when the patient reacts.
2.
Professional dental scaling includes scaling the surfaces of the teeth both
above and below the gingival margin (gum line), followed by dental polishing.
The most critical part of a dental scaling procedure is scaling the tooth
surfaces that are within the gingival pocket (the subgingival space between the
gum and the root), where periodontal disease is active. Because the patient
cooperates, dental scaling of human teeth performed by a professional trained
in the procedures can be completed successfully without anesthesia. However,
access to the subgingival area of every tooth is impossible in an
unanesthetized canine or feline patient. Removal of dental tartar on the
visible surfaces of the teeth has little effect on a pet's health, and provides
a false sense of accomplishment. The effect is purely cosmetic.
3.
Inhalation anesthesia using a cuffed endotracheal tube provides three important
advantages... the cooperation of the patient with a procedure it does not
understand, elimination of pain resulting from examination and treatment of
affected dental tissues during the procedure, and protection of the airway and
lungs from accidental aspiration.
4. A
complete oral examination, which is an important part of a professional dental
scaling procedure, is not possible in an unanesthetized patient. The surfaces
of the teeth facing the tongue cannot be examined, and areas of disease and
discomfort are likely to be missed.
Safe use
of an anesthetic or sedative in a dog or cat requires evaluation of the general
health and size of the patient to determine the appropriate drug and dose, and
continual monitoring of the patient.
Veterinarians
are trained in all of these procedures. Prescribing or administering anesthetic
or sedative drugs by a non-veterinarian can be very dangerous, and is illegal.
Although anesthesia will
never be 100% risk-free, modern anesthetic and patient evaluation techniques
used in veterinary hospitals minimize the risks, and millions of dental scaling
procedures are safely performed each year in veterinary hospitals.
For more
information on why AVDC does not recomemnd Non-anesthetic (Anesthesia-free)
Dentistry, click this link:
American College of Veterinary Anesthesia [ACVA] Monitoring Guidelines
Dr. DeForge follows the ACVA Guidelines for Monitoring
anesthetized veterinary patients in all Centers and Veterinary Hospitals in
which he maintains a Veterinary Consulting and Treatment Dentistry Service
Position Statement
The ACVA recognizes that it is possible to adequately monitor and
manage anesthetized patients without specialized equipment and that some of
these modalities may be impractical in certain clinical settings. Furthermore,
the ACVA does not suggest that using any or all the modalities will ensure any
specific patient outcome, or that failure to use them will result in poor
outcome.
However,
as the standard of veterinary care advances and client expectations expand,
revised guidelines are necessary to reflect the importance of vigilant
monitoring. The goal of the ACVA guidelines is to improve the level of
anesthesia care for veterinary patients. Frequent and continuous monitoring and
recording of vital signs in the peri-anesthetic period by trained personnel and
the intelligent use of various monitors are requirements for advancing the
quality of anesthesia care of veterinary patients.
Circulation
Objective: to ensure adequate
circulatory function.
Methods:
1)
Palpation
of peripheral pulse to determine rate, rhythm and quality, and evaluation of
mucous membrane (MM) color and capillary refill time (CRT).
2)
Auscultation
of heart beat (stethoscope; esophageal stethoscope or other audible heart monitor).
Continuous (audible heart or pulse monitor) or intermittent monitoring of the
heart rate and rhythm.
3)
Pulse
oximetry to determine the % hemoglobin saturation.
4)
Electrocardiogram
(ECG) continuous display for detection of arrhythmias.
5)
Blood
pressure:
a.
Non-invasive
(indirect): oscillometric method: Doppler ultrasonic flow detector
b.
Invasive
(direct): arterial catheter connected to an aneroid manometer or to a
transducer and oscilloscope.
Recommendations:
Continuous
awareness of heart rate and rhythm during anesthesia, along with gross
assessment of peripheral perfusion (pulse quality, mm color and CRT) are
mandatory. Arterial blood pressure and ECG should also be monitored. There may
be some situations where these may be temporarily impractical, e.g. movement of
an anesthetized patient to a different area of the hospital.
Oxygenation
Objective: to ensure adequate
oxygenation of the patient’s arterial blood.
Methods:
(1) Pulse oximetry
(non-invasive estimation of hemoglobin saturation).
(2) Arterial blood
gas analysis for oxygen partial pressure (PaO2).
Recommendations:
Assessment
of oxygenation should be done whenever possible by pulse oximetry, with blood
gas analysis being employed when necessary for more critically ill patients.
Ventilation
Objective: to ensure that the
patient’s ventilation is adequately maintained.
Methods:
(1) Observation of
thoracic wall movement or observation of breathing bag movement when thoracic
wall movement cannot be assessed.
(2) Auscultation of
breath sounds with an external stethoscope, an esophageal stethoscope, or an
audible respiratory monitor.
(3) Capnography
(end-expired CO2 measurement).
(4) Arterial blood
gas analysis for carbon dioxide partial pressure (PaCO2).
(5) Respirometry
(tidal volume measurement).
Recommendations:
Qualitative
assessment of ventilation is essential as outlined in either 1 or 2 above, and
capnography.
Temperature
Objective: to ensure that
patients do not encounter serious deviations from normal body temperature.
Methods:
(1) Rectal
thermometer for intermittent measurement.
(2) Rectal or
esophageal temperature probe for continuous measurement.
Recommendations:
Temperature
should be measured periodically during anesthesia and recovery and if possible
checked within a few hours after return to the wards.
Record Keeping
Objectives:
(1)
To maintain a legal record of significant events related to the anesthetic
period.
(2)
To enhance recognition of significant trends or unusual values for physiologic
parameters and allow assessment of the response to intervention.
Recovery Period
Objective: to ensure a safe
and comfortable recovery from anesthesia.
Methods:
(1)
Observation of respiratory pattern.
(2)
Observation of mucous membrane color and CRT.
(3)
Palpation of pulse rate and quality.
(4)
Measurement of body temperature, with appropriate warming or cooling methods
applied if indicated.
(5)
Observation of any behavior that indicates pain, with appropriate
pharmaceutical intervention as necessary.
(6)
Other measurements as indicated by patient’s medical status, e.g. blood
glucose, pulse oximetry, PCV, TP, blood gases, etc.
Recommendations
Monitoring
in recovery should include at the minimum
evaluation of pulse rate and quality, mucous membrane color, respiratory
pattern, signs of pain, and temperature.
Personnel
Objective: to ensure that a
responsible individual is aware of the patient's status at all times during
anesthesia and recovery, and is prepared either to intervene when indicated, or
to alert the veterinarian in charge about changes in the patient's condition.
Recommendations:
(1) Ideally, a
veterinarian, technician, or other responsible person should remain with the
patient continuously and be dedicated to that patient only
(2) If this is not possible, a reliable and
knowledgeable person should check the patient's status on a regular basis (at
least every 5 minutes) during anesthesia and recovery
(3) A responsible
person may be present in the same room, although not necessarily solely
occupied with the anesthetized patient (for instance, the surgeon may also be
responsible for overseeing anesthesia)
(4) In either of (2)
or (3) above, audible heart and respiratory monitors must be available.
(5) A responsible
person, solely dedicated to managing and caring for the anesthetized patient
during anesthesia, remains with the patient continuously until the end of the
anesthetic period.
The Anesthesia Journey:
Whether human or
animal, the anesthesia journey always carries risk. Risk factors are always measured in relationship
to quality of life and restoring a pain free life.
“Aging of biological systems occurs in spite of numerous complex
pathways of maintenance, repair and defense. There are no gerontogenes which have the specific evolutionary
function to cause aging. Although aging
is the common cause of all age-related diseases, aging in itself cannot be
considered a disease.” SENS
Research Foundation.
Because aging is a characteristic of all species, we cannot look
away from the aging companion and not address their needs. To the contrary, the needs of the geriatric
companion animal are much greater than any other stage of life necessitating
even greater scrutiny. The oral needs of
companion animals of all ages and all stages of life are unique and must only
be undertaken after pre-anesthesia scrutiny.
Sometimes this also requires an Internist or a Cardiologist intervention
to work as a team with the generalist.
With this health-care team---- of pet advocate; generalist; and
animal dentist ,---- all patients will be treated and all oral problems
reversed, that can be reversed, bringing a pain free quality of life. There is little else that our companions who
provide unconditional love will
ever ask of us! Intervention and
reversal of pathology that causes discomfort is a minor way of showing our love
to them.
