The Pathway to New Millennium Optimal Oral Care
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:
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
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.
Objective: to ensure adequate circulatory function.
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.
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.
Objective: to ensure adequate oxygenation of the patient’s arterial blood.
(1) Pulse oximetry (non-invasive estimation of hemoglobin saturation).
(2) Arterial blood gas analysis for oxygen partial pressure (PaO2).
Assessment of oxygenation should be done whenever possible by pulse oximetry, with blood gas analysis being employed when necessary for more critically ill patients.
Objective: to ensure that the patient’s ventilation is adequately maintained.
(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).
Qualitative assessment of ventilation is essential as outlined in either 1 or 2 above, and capnography.
Objective: to ensure that patients do not encounter serious deviations from normal body temperature.
(1) Rectal thermometer for intermittent measurement.
(2) Rectal or esophageal temperature probe for continuous measurement.
Temperature should be measured periodically during anesthesia and recovery and if possible checked within a few hours after return to the wards.
(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.
Objective: to ensure a safe and comfortable recovery from anesthesia.
(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.
Monitoring in recovery should include at the minimum evaluation of pulse rate and quality, mucous membrane color, respiratory pattern, signs of pain, and temperature.
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.
(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.