Thursday, February 23, 2017

When Should I See An Animal Dentist? No. 20

Centers for Oral Care
New England & New York
Animal Dental Health Services
No. 20~ 23February2017
DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry

When Should I See An Animal Dentist?

Do you remember taking your child to the dentist for the first time?  It may have been a lark or it may have been a catastrophe but it will always be a loving memory.

What about your first visit to an animal dentist.  Maybe you have never met an animal dentist;  do not know who they are; or why you would ever need to visit an animal dentist.  Read on!

Most veterinarians are highly trained in routine oral care.  They perform teeth cleanings and help treat the earliest form of Periodontal Disease called GINGIVITIS.  Years ago before veterinary dentists entered the theater of oral care if a veterinarian did not know the cause of a tooth problem and……… because that general practitioner did not have dental x-ray………. all “abnormal” teeth were extracted. 

Today, veterinary dentists applaud the veterinary general practice doctor who has taken the time to take continuing education courses in the routine oral care of their patients and have brought dental x-ray to their hospital.  The animal dentist and the general practice doctor have become a strong team in the New Millennium!

Yes, times have changed with the advent of modern animal dentistry.  There are now veterinary dentists available to help companions who suffer from a plethora of oral problems. The question to ponder is when should you seek out an animal dentist?

A Good Question:

That is a good question.  First and foremost, you should speak with your local doctor of veterinary medicine who will guide you in this referral.  Most general veterinary practitioners are educated and trained to treat early forms of gum disease. Some take extra training to learn the skills required to treat more advanced forms of disease. Animal dentists work hand in hand with general veterinary doctors to diagnose and manage periodontal and other dental problems as part of a multi-team one-medicine approach.

  Let us take a simple example: diseases of the gums in companion animals.  Early “gum-disease” is most often treated by general practice veterinary doctors.  Advanced  “gum disease is, commonly, referred to an animal dentist.

Let us look at the human model.  When a human general dentist sees that the “gum-disease” they are treating is not responding they call in a periodontist!  Why a periodontist?  Let us look at the word periodontist (“peri” – means around; “odont” – means tooth)  A Periodontist is a dentist who specializes in the treatment of abnormal bone and connective tissues that surround and support your teeth!

Animal dentistry has not broken up into the many sub- specialties found in human dentistry.  One of the roles that animal dentists have taken on is the role of “animal periodontist”!  They have become an advanced alternative in the diagnosis and treatment of all disorders and diseases of the supporting structures of the teeth.

 Periodontal (gum) disease is a broad term for a group of different diseases, all of which have the same outcome: loss of attachment of the gingiva and mucosa, connective tissue, and bone to the teeth.

 It is described as the Periodontal Attachment Apparatus. The "attachment apparatus," refers to the cementum, periodontal ligament, and alveolar bone that attaches the tooth to the bone.  Most periodontal diseases are caused by the bacterial biofilm that collects around the teeth from ineffective oral hygiene coupled with a defective immune system.

Today, animal periodontal medicine encompasses how periodontal disease and systemic (general body) disease impact each other. Recent studies have reported that almost fifty percent of companion animals over four years of age suffer from some form of periodontal disease.

How Do You Know Your Pet Has Periodontal (Gum) Disease?

Early warning signs may be slight bleeding when you brush your pet’s teeth; slight redness and inflammation of the gum margins; and bad breath.  Your pet may be avoiding treats that are hard; or only will eat canned or table food; and refuses dry dog food. Later symptoms and consequences that you will recognize include abscesses, loose or moving teeth, and ultimately tooth loss.  All of these can cause pain to your pet!

The treatment of the different forms of periodontal diseases depends upon their cause. Accurate diagnosis begins with a comprehensive periodontal oral health assessment and evaluation with dental x-rays by the animal dentist!

Most early to moderate periodontal diseases have one common treatment objective:  Instructing the pet owner in achieving optimum daily biofilm removal and (plaque) control.  This is achieved with a selective form of professional care coupled with a homecare anti-plaque program that is unique to the pet being treated.  Your pet receives a thorough professional teeth cleaning — known as scaling and root planing or root debridement.  Moderate to advanced disease may require surgical periodontal  treatment.

If you have a periodontal concern, a good place to start is by talking to your general animal doctor or family veterinarian who will refer you to an animal dentist if they feel that your condition warrants it; or if your treatment needs are beyond the scope of that particular general practice animal doctor. Any general veterinary doctor who treats periodontal gum disease must treat to the same standards as an animal dentist; therefore if you are accepted for treatment, you should be in good hands.

If you have already seen a general practice veterinary doctor and you would like a second opinion;  you should seek the animal dentist of your choice or ask for a referral from your family veterinarian.  It is helpful if you have your previous dental and medical records available for the animal dentist.  It is always best for your regular doctor of veterinary medicine to work as a team with the animal dentist.

If you are concerned that you may have advanced periodontal disease or you already have periodontal disease coupled with systemic disease such as diabetes; kidney disease; liver disease; hypertension; or cardiovascular [heart] disease, you may consider seeing an animal dentist immediately.

Other Reasons to Seek Out An Animal Dentist:

Jaw fractures

Oral Pain

Broken Teeth that need Root Canals

Cats and Dog with Oral Ulcers

Tumors or Growths in the Mouth

Stomatitis Disease in Cats

Difficult Extractions-especially in toy and small breeds

Boxers with overgrowth of gum tissue

Cats and dogs with cavities

Occlusion Problems

The animal dentist wears “many hats” and has been trained to perform procedures in all intradisciplines of dentistry.  Talk to your general doctor and get their input and advice on a referral to an animal dentist about any of the above problems.  Never let a pet live in pain!  When seeking out an animal dentist “hope is on the way” for a pain free quality of  life.

Thursday, February 16, 2017

No. 19 Animal Anesthesia and Oral Care Patient

DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry

Pre-Anesthesia Examination
Animal Anesthesia and
The Oral Care Patient--Blog #19

Pre-Anesthesia Examination and Testing Requisites-ACVA Monitoring Guidelines-ASA Patient Status Classification
Companion animal advocates are very concerned when the pet that they love needs to undergo general inhalation anesthesia for any reason. 

To assist the pet advocate, this abstract will review Pre-Anesthesia Examination and Testing; ACVA Anesthesia Monitoring Guidelines; and ASA Pre-Anesthesia Physical Status Classification.

f veterinary preoperative medical assessment and human preoperative assessment are identical.  The goal of exam and testing is to reduce the patient’s surgical and anesthetic peri-operative morbidity or mortality, and to return the patient to normal functioning and a pain free quality of life as quickly as possible.

 It is imperative to realize that anesthesia risk and recovery from anesthesia risk is multi-factorial and a function of the preoperative medical condition of the patient; the invasiveness of the surgical procedure; and the type of anesthetic administered.

A history and physical examination is critical with emphasis on risk factors for cardiac and pulmonary complications.  Laboratory investigations must be ordered based on the patient’s age; medical status; drug therapy; or the nature of the proposed procedure. 
Those veterinary patients with co-morbidity should be optimized for the procedure.  Proper consultations with appropriate medical specialists should be scheduled to improve the patient’s health prior to anesthesia if indicated.

These consultations should ideally not be done in a "last second" fashion. The pre-operative preparation involves procedures that are implemented based on the nature of the expected operation as well as the findings of the diagnostic workup and the pre-operative evaluation.
The referring doctor-LDVM-RDVM-GDVM-can spear head and complete all exams and testing or refer to a specialist for that testing.
Listed below are many of the tests that your family doctor or Specialist may order based on the age of the patient; pre-existing medical health of the patient; and/or other factors noted in past Medical Records.  

It is critical to know if any patient referred has had any adverse history with anesthesia, sedation, and/or analgesic medicines in the past.

Pre-Anesthesia Testing Modules
 [          } Physical Exam

[          ] Comprehensive Chemistry Profile and CBC

[          ] Urinalysis

[          ] Feline Leukemia-Immunodeficiency-and Bartonella Testing at National Veterinary Lab

[          ] CardioPet proBNP / Feline *

[          ] IDEXX SDMA Biomarker for Kidney Function (IDEXX Adult Wellness

[          ] Blood Pressure

[          ] Coagulation Testing [PT/PTT/BMBT]

[          ] Electrocardiogram

[          ] Chest Radiology

[          ] Echocardiogram

[          ] Abdominal Sonogram

[          ] Internal Medicine Consult and Pre-Anesthesia Testing

[          ] Cardiologist Consult

ACVA Monitoring Guidelines Update

Recommendations for monitoring anesthetized veterinary patients

Position Statement 2009
The American College of Veterinary Anesthesiologists (ACVA) has revised the set of guidelines for anesthetic monitoring that were originally developed in 1994 and published in 19951.  Since then many factors have caused a shift in the benchmark used to measure a successful anesthetic outcome, moving from the lack of anesthetic mortality toward decreased anesthetic morbidity. 

This shift toward minimizing anesthetic morbidity has been facilitated by more objective definition and earlier detection of pathophysiologic conditions such as hypotension, hypoxemia and severe hypercapnia. This has resulted from the incorporation of newer monitoring modalities by skilled attentive personnel during anesthesia.

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.

1. JAVMA 1995; 206(7): 936-937.
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 is recommended, with blood gas analysis as necessary.

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.

Neuromuscular Blockade

Objective: to assess the intensity of and recovery from neuromuscular blockade.

(1) Hand-held peripheral nerve stimulator.
(2) Spirometer.

For any patient in which neuromuscular blockade is used, it is essential to control ventilation, monitor closely for signs of awareness, and be certain of recovery of blockade prior to anesthesia recovery. Recovery of neuromuscular function may be assumed if the evoked response (twitch and/or tetanic fade) to a nerve stimulus, and respiratory tidal volume as measured with a spirometer, return to at least 70% of pre- blockade status. End tidal CO2 may also be used as an indication of adequate ventilation in spontaneously ventilating patients.
Record Keeping
(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.

(1) Record all drugs administered to each patient in the peri-anesthetic period and in early recovery, noting the dose, time, and route of administration, as well as any adverse reaction to a drug or drug combination.
(2) Record monitored variables on a regular basis (minimum every 5 to 10 minutes) during anesthesia. The minimum variables that should be recorded are heart rate and respiratory rate, as well as oxygenation status and blood pressure if these were monitored.
(3) Record heart rate, respiratory rate, and temperature in the early recovery phase.
(4) Any untoward events or unusual circumstances should be recorded for legal reasons, and for reference should the patient require anesthesia in the future.
Recovery period
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.(a, b)

a) Recommended for all patients assessed as ASA status III, IV, or V
b) Recommended for horses anesthetized with inhalation anesthetics and/or horses anesthetized for longer than 45 minutes

ASA Patient Status: The American Society of Anesthesiologists has developed a classification system for human patient physical status. This system has been widely adapted to veterinary patients. It is important to recognize that the ASA status is not equal to patient risk classification, although a correlation does exist between physical status and outcome. Some additional risk factors that do not contribute to ASA status, but that do contribute to patient outcome, include anesthetist experience, surgeon experience, facilities and availability of monitoring and emergency care, and performance of anesthesia outside normal hours.
ASA I--- A normal healthy patient

ASA II--- A patient with mild systemic disease

ASA III--- A patient with severe systemic disease

ASA IV--- A patient with severe systemic disease that is a constant threat to life

ASA V--- A moribund patient who is not expected to survive without the operation


Monday, February 13, 2017

Blog 18 Periodontal Disease Part 2

Centers for Oral Care
New England & New York
Animal Dental Health Services
No. 18~13Feb2017
DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry

Periodontal Disease
Part Two
Professional Techniques in Removing Plaque- Biofilm

Abstract:  In Part Two of this Three Part series you will find a summary of Ultrasonic Debridement Techniques concerning plaque biofilm removal by the veterinary dentist; veterinarian trained in periodontal care; and the well educated veterinary dental hygienist.  There is a difference between the Periodontal Prophylaxis in the young dog or cat with gingivitis as compared to the older patient with periodontitis.  By four years of age, especially in small and toy breeds, periodontal diseases can be quite advanced.  In many instances, these and older patients may need referral to a veterinary dentist for Comprehensive Oral Health Assessment and Treatment.  Once diagnostics are completed and oral health is restored, the patient can be returned to the general practitioner for follow-up home care monitoring and continued supportive periodontal care under general inhalation anesthesia.

The  Beginning:
Once manual hand root planing is mastered, the veterinarian or veterinary dental technician should consider piezoelectric ultrasonic debridement.  Piezo- electric ultrasonic mechanics is activated by the expansion and contraction of quartz crystals to provide a frequency of 20-45 KHz.  Most authors feel that the piezoelectric units operate with a curved linear tip movement while others describe elliptical as well as linear movement based on power setting and water flow.

Water flow from the working tip’s insert cools the tooth surface.  Piezoelectric curettes affect excellent supragingival crown scaling- and subgingival root planing.

Piezoelectric Mechanisms of Action
Vibratory action of the oscillating metal tip against the deposit breaks the deposit from the tooth surface
Lavage action of water flowing over tip flushes biofilm-plaque from the tooth surface and debris from the treatment site
Removal/disruption of biofilm by shock waves resulting from the implosion of bubbles

Piezoelectric debridement is excellent in reducing pocket depth and gingival inflammation.  This debridement helps to eliminate bacteria pathogens by disrupting subgingival biofilm.  Mini-inserts allow access to deep narrow pockets with excellent debridement that is expedient and more efficient than manual root planing with curettes.  Some areas may need both manual and mechanical debridement.  Only with experience and multiple wet-labs will the veterinarian or animal dental hygienist be able to determine the most efficient combination of methods of root planing.  No effective periodontal care is possible without gas inhalation anesthesia. [See Periodontal Disease Professional Care and Home Care- Part One- No. 16- 20Jan2017

The end result is always the same: a debris free subgingival root surface.  With proper piezoelectric technique, there is less damage to healthy cementum, than with manual root planing when the unit is set at the manufacturer’s recommended power settings.
Abnormal pocket depth noted during debridement should be a red flag to initiate periapical oral x-rays.
Understanding the differences between reversible gingivitis and irreversible but controllable periodontitis should be a part of all veterinary oral care staff’s continuing education. 
Listed below is the Sequence Patterns of Advanced Periodontitis.  All of the below can be avoided with professional dental exams; site specific oral radiology; professional treatment based on oral x-ray findings; and an excellent homecare anti-plaque program.

Sequence Patterns of Advanced Periodontitis
Plaque-biofilm deposits
Calculus formation
Gingival inflammation
Pathologic pocket formation
Bone resorption
Hyperplastic gingiva
Gingival bleeding
Gingival recession
Furcation exposure between roots
Tooth mobility
Root exposure and cementum loss
Apical periodontitis
Osseous destruction and Infrabony pockets
Tooth exfoliation
Sinus pathology
Fistulous tracts
Pathologic fractures

Very soon the Market Place section of our Website: will open.  This is a defining area of materials and equipment that will help the companion animal practitioner in their journey in animal dentistry.

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