Antibiotics for dentals.

Re: Antibiotics for dentals.

Rachel Perry — Sat, 20 Oct 2012 09:05:27 GMT

[quote user="David Mills"]

Possibly not. What's the evidence? Is it based on referral populations? Again, I would wager unnecessary in the vast majority of dentals.

[/quote]

There is loads of evidence out there. These two papers demonstrate that even specialists cannot detect every lesion in the mouth without radiography.

Am J Vet Res. 1998 Jun;59(6):692-5.

Diagnostic value of full-mouth radiography in cats.

Verstraete FJ, Kass PH, Terpak CH.

Source

Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California 95616, USA.

Abstract

OBJECTIVE:

To determine the diagnostic value of full-mouth radiography in cats.

SAMPLE POPULATION:

115 cats referred for dental treatment without a previous full-mouth radiographic series available.

PROCEDURE:

In a prospective nested case-control analysis of multiple outcomes in a hospital cohort of cats referred for dental treatment, full-mouth radiography was done prior to oral examination and charting. After treatment, the clinical and radiographic findings were compared, with reference to presenting problems, main clinical findings, additional information obtained from radiography and unexpected radiographic findings. Importance of the radiographic findings in therapeutic decision making was assessed.

RESULTS:

The main clinical findings were radiographically confirmed in all cats. Odontoclastic resorption lesions, missed on clinical examination, were diagnosed in 8.7% of cats. Analysis of selected presenting problems and main clinical findings yielded significantly increased odds ratios for a variety of other conditions, either expected or unexpected. Radiographs of teeth without clinical lesions yielded incidental or clinically important findings in 4.8 and 41.7% of cats, respectively, and were considered of no clinical value in 53.6%. Radiographs of teeth with clinical lesions merely confirmed the findings in 13.9% of cats, but yielded additional or clinically essential information in 53.9 and 32.2%, respectively.

CLINICAL RELEVANCE:

The diagnostic yield of full-mouth radiography in new feline patients referred for dental treatment is high, and routine use of full-mouth radiography is justifiable.

Am J Vet Res. 1998 Jun;59(6):686-91.

Diagnostic value of full-mouth radiography in dogs.

Verstraete FJ, Kass PH, Terpak CH.

Source

Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis 95616, USA.

Abstract

OBJECTIVE:

To determine the diagnostic value of full-mouth radiography in dogs.

SAMPLE POPULATION:

Prospective series of 226 dogs referred for dental treatment without previous full-mouth radiographic views being available.

PROCEDURE:

In a prospective nested case-control analysis of multiple outcomes in a hospital cohort of dogs presented for dental treatment, full-mouth radiographic views were obtained prior to oral examination and charting. After treatment, clinical and radiographic findings were compared, with reference to presenting problems, main clinical findings, additional information obtained from the radiographs, and unexpected radiographic findings. The importance of the radiographic findings in therapeutic decision-making was assessed.

RESULTS:

The main clinical findings were radiographically confirmed in all dogs. Selected presenting problems and main clinical findings yielded significantly increased odds ratios for a variety of other conditions, either expected or unexpected. Radiographs of teeth without clinical lesions yielded incidental or clinically important findings in 41.7 and 27.8% of dogs, respectively, and were considered of no clinical value in 30.5%. Radiographs of teeth with clinical lesions merely confirmed the findings in 24.3% of dogs, yielded additional or clinically essential information in 50.0 and 22.6%, respectively, and were considered of no value in 3.1%. Older dogs derived more benefit from full-mouth radiography than did younger dogs. Incidental findings were more common in larger dogs.

CLINICAL RELEVANCE:

Diagnostic yield of full-mouth radiography in new canine patients referred for dental treatment is high, and the routine use of such radiographs is justifiable.

Re: Antibiotics for dentals.

Rob Davis — Fri, 19 Oct 2012 08:55:57 GMT

I voted for "none".

I would qualify that by pointing out that each case needs to be individually assessed, but I don't believe that the majority of dental procedures require antibiosis. My understanding is that animals with severe periodontitis induce bacteraemia every time they eat - their immune system is already coping with bacteraemia daily. Adequate oral cleansing during the procedure should be removing the bacterial load, so there should be no requirement for post-procedure antibiosis in most cases. There are some exceptions: I tend to use antibiotics in dogs with valvular heart disease, orthopaedic implants etc. In these cases a single dose of IV antibiotics (or sc amoxyclav with pre-med) should provide adequate systemic antibiosis when needed (ie when inducing the bacteraemia). I don't see the advantage of using pre-op antibiotics in most cases (though as Rachel has said, there are some indications such as feline chronic gingivo-stomatitis).

As far as radiography is concerned, as others have already suggested, if you haven't ever done it, you just don't realise what you are missing. I take radiographs during the majority of my dental procedures, and it genuinely surprised me when I started doing it how much pathology I would have missed previously.

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Thu, 18 Oct 2012 22:39:44 GMT

Oh, this is so depressing, but you are right, I can't help it.

[quote user="David Mills"]QED. You dentists really can't help yourselves, eh?[/quote]

Nor you, we've known that a while.

[quote user="David Mills"]invariably these are one-stop shop dentals.[/quote]

Only because you choose to make them so.

[quote user="David Mills"] In fact there's a reaonable argument that if you need to do a dental then the dental care has been inadequate, so what chance getting a likely adult/elderly dog to accept tooth brushing? [/quote]

Big non-sequitur.

And toothbrushing, which may not even be part of the plan at all, is only part of the concept of oral hygiene.

If you tell your clients (do you have clients?) either explicitly or tacitly that oral hygiene is rubbish, toothbrushing is impossible, any tooth with anything wrong with it simply needs to be pulled out and anything else is just fancy and expensive, naturally that's going to be your clients' attitude too.

[quote user="David Mills"]White tower pie in the sky. [/quote]

Thank you for that, lovely. One of Nigella's?

Re: Antibiotics for dentals.

Rajat — Thu, 18 Oct 2012 22:37:11 GMT

My 2 c...

Good dentistry is not difficult neither expensive. Dental radiography pays for itself very quickly- and is a joy to use and obtain a better understanding of what is happening in the mouth. Like today I had FME(not canines) on a calici +ve chronic gingivostomatitis cat. Full mouth rads prior to extractions showed several incisors that were missing and had fractured off leaving the roots in place. Also helped to guide and check all roots are out afterwards. Those who haven't been exposed to this don't know what they are missing, and not to step on the dental gurus toes but if anyone wants some info on an excellent dental radiography system PM me (we bought 2 in the last 3 years and our second one is the dogs nuts..!)

Maybe its where I work (suburban London) but I find most clients happy to pay for their pets oral care. Many are persuaded to have dental treatments yearly- I am frank and say look, I cant brush my cats teeth so I do what I can but accept I will have to scale polish etc once yearly as she gets ginigvitis easy. Most ppl accept it as a basic need especially when shown the pretty pictures before and after and the rads and how much the bone has receded by- images speak louder than words, and I believe these things re-inforce to the client the importance of home oral care.

Re radiographs- there is no doubt they are useful - as for the cost- they are cheap and don't add that much to the dental (10% or less). We don't give clients a choice in the matter- the truth is radiographs ARE needed for most if not all dental procedures and it is a clinical decision not a client decision.

Asking for evidence for dental radiographs is a bit OTT. Can someone provide evidence that xrays help in the management of asthma? A controlled study? Sounds ridiculous doesn't it?

Re: Antibiotics for dentals.

David Mills — Thu, 18 Oct 2012 22:20:54 GMT

[quote user="Rachel Perry"]

Root planing cannot be likened to TTAs and MRIs. You can diagnose periodontal pockets with a £7 periodontal probe (free if you ask your Pfizer rep) and perform root planing with a £10 curette. If you are not sure of the technique, you can watch it on YouTube for free. This is not 'fancy stuff', but what anyone with an interest in and knowledge of dentistry in pets would consider 'good clinical practice' .Takes a couple of minutes to root plane a canine tooth, charge a reasonable fee (call it a tenner- cheaper than most injection fees)....

[/quote]

QED. You dentists really can't help yourselves, eh?

Thanks for the words in mouth. I never likened root planing to MRIs or TTAs. I think most people can root plane. Much of the time I choose not to, because invariably these are one-stop shop dentals. If there's a periodontal pocket, out it comes. In fact there's a reaonable argument that if you need to do a dental then the dental care has been inadequate, so what chance getting a likely adult/elderly dog to accept tooth brushing? White tower pie in the sky.

[quote user="Rachel Perry"]

This is not fancy pants- if we can radiograph legs and chests then why not the mouth?

[/quote]

Possibly not. What's the evidence? Is it based on referral populations? Again, I would wager unnecessary in the vast majority of dentals.

Re: Antibiotics for dentals.

Malcolm Ness — Thu, 18 Oct 2012 21:30:37 GMT

[quote user="Rachel Perry"]Treating periodontal disease is not like fixing a broken leg: a one-stop-shop[/quote]

Dentists! Don't you just love them?

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Thu, 18 Oct 2012 21:23:29 GMT

[quote user="Dagmar Steele"] Example from 30 minutes ago: 17yo female cat with skin rash, drinks a lot, has lost weight and needs examination of teeth as well as blood work and so on, last visit to the vet donkeys ages ago. I was allowed to treat the mites but the rest of my suggestions was answered with "these things come with old age"[/quote]

Yes, I get that sort of thing from time to time.

[quote user="Dagmar Steele"] I would like to discuss though if it is better to leave them completely alone or to pull out what seems to be not ok any more? I have decided for myself that each rotten tooth I pull is less pain for the dog - but I may stand corrected if someone can explain to me why I should do nothing instead of basic work ?[/quote]

[quote user="Mark Holmes"]

[quote user="Rachel Perry"]Periodontal disease cannot.[/quote]

It can if you pull them out.

[/quote]

As I've said, of course you shoudn't do nothing, and by all means extract if you decide it's the only thing.......... but if you extract every diseased tooth you are going to spend an awfully large proportion of your life extracting teeth.

Come to think of it, why not extract every tooth from the patient the first time you treat its teeth at all? Then the client will never need to come back.

Maybe do a bilateral TECALBO while you're about it, if it's got any otitis.

Re: Antibiotics for dentals.

Dagmar Steele — Thu, 18 Oct 2012 17:18:18 GMT

[quote user="Rachel Perry"]

I am perfectly capable of doing this and I know how to do it, I even have the tools to do it and I didn't have to beg to have them for free, no need to be educated on youtube any more :-)

Every veterinary dentist I know would far rather an animal have no teeth than be left with infected or painful teeth. We don't sniff at extractions. However, there are good and bad extraction techniques, and some bad extraction techniques potentially can leave the animal worse off (I've seen a few over the years).

very true and I'm thoroughly hoping that I've done well so far though I must admit I have had a deserved complaint once.

Nobody is saying every patient should be radiographed (althought there is actually good evidence to show you probably should radiograph every patient), but if, on oral exam (with your trusty periodontal probe) you find pathology then that's an indication for radiography. This is not fancy pants- if we can radiograph legs and chests then why not the mouth?

Oh if I only could radiograph every leg and every chest I want to. I do so frequently, but sometimes I hit rock bottom even if you can feel the crepitation.

[/quote]

Re: Antibiotics for dentals.

Rachel Perry — Thu, 18 Oct 2012 17:08:50 GMT

[quote user="David Mills"]

[quote user="Evelyn Barbour-Hill"]

[/quote]

Meanwhile in the real world people want their animals' teeth sorting out, preferably on one occasion. As others have alluded to, fancy things may be possible in dentistry, and successfully so, but like TTAs or MRIs they are generally the preserve of people who can afford such. Extraction is not, in animals, because of the variability in aftercare, an option to be sniffed at by dentists (why, amongst specialists, are they apparently the most didactic?). Animals can function perfectly well with no teeth and, really, this talk of xraying every patient and root planing is pie in the sky to >90% of what happens. Are we expected to believe, hallowed dentists, that these animals treated are somehow 'worse off'?

[/quote]

Re: Antibiotics for dentals.

Mark Holmes — Thu, 18 Oct 2012 17:02:31 GMT

[quote user="Rachel Perry"]Periodontal disease cannot.[/quote]

It can if you pull them out. Many of the clients have hideous periodontal disease and a handful of teeth sometimes even in their 20's. Very very few vets manage dental care in their own animals and we are better informed than clients will ever be. Expecting things from our cleints that we cannot manage ourselves is unrealistic. Yes there will be some exceptions but in general keeping up a level of interest is headbanging. Its like getting aniimals to lose weight, you need to REALLY appreciate those that do, because in general clients start well and then give up.

Re: Antibiotics for dentals.

Dagmar Steele — Thu, 18 Oct 2012 16:59:39 GMT

I asked for it I know :-) I refer a lot of my dentistry and the people that agree are prepared to pay bucks for good work. But they are the minority. You'll probably never come across the majority of my clients - they wouldn't set a foot in your practice as they'd expect you (as a specialist) to be expensive, even if this is not the case. Don't think it doesn't depress me to not work up to good standards, it is one of the most disappointing things I come across. And maybe I wasn't precise enough, I do think about what to take out and what to leave in and I rather pull than leave in when suspecting bad compliance. Example from 30 minutes ago: 17yo female cat with skin rash, drinks a lot, has lost weight and needs examination of teeth as well as blood work and so on, last visit to the vet donkeys ages ago. I was allowed to treat the mites but the rest of my suggestions was answered with "these things come with old age", all my remarks about quality of living/pain/welfare were wiped away by the elderly man bringing the cat in.

I fully understand that someone doing teeth properly has to bang his head in despair over what I sometimes do. I would like to discuss though if it is better to leave them completely alone or to pull out what seems to be not ok any more? I have decided for myself that each rotten tooth I pull is less pain for the dog - but I may stand corrected if someone can explain to me why I should do nothing instead of basic work ?

Again, it's not that I don't mention what should be done!

Re: Antibiotics for dentals.

Rachel Perry — Thu, 18 Oct 2012 16:47:52 GMT

[quote user="David Mills"]

Meanwhile in the real world people want their animals' teeth sorting out, preferably on one occasion.

[/quote]

If clients believe this then we have not done our job in correctly informing them of the disease process. Treating periodontal disease is not like fixing a broken leg: a one-stop-shop. If the client is not informed that periodontal disease is an ongoing disease that can be managed (with homecare and professional trips to you) then no wonder they seem suprised that you are suggesting further dental work one year down the line ("whaddya mean he needs another dental he had one last year?!"). It's our responsibility to educate clients about disease processes in their pets. Some dental problems can be addressed in a one-off visit. Periodontal disease cannot.

Re: Antibiotics for dentals.

James Laidlaw — Thu, 18 Oct 2012 16:39:13 GMT

I'm lucky enough now to work in a clinic with decent digital radiography for dental work, and I have been quite surprised what I have found that I would otherwise have missed in terms of fractured roots, root remnants, retained teeth. I also understand it's not all that expensive to get kitted out with dental x-ray stuff, and it pays for itself. Clients like to be able to see what we've done and why we've done it - I don't think I'd like to go back to how I had to work before now that I've used this stuff!

Just my 2p.

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Thu, 18 Oct 2012 15:35:08 GMT

[quote user="David Mills"]

[quote user="Evelyn Barbour-Hill"]

Sorry, Dagmar, i'm not making you a target, but your post seems to symbolise an attitude and I find it thoroughly depressing.

[/quote]

You've missed my point, Mr. Mills, you really have. I'm not sniffing at extraction as a treatment option. I emphasised that among the factors in deciding whether to extract or not is the likelihood of good oral hygiene afterwards. If you are sure that there won't be good oral hygiene, then extract the thing. (As long as you are competent at extraction, of course). By all means extract every tooth – I did suggest that – but bear in mind it may take quite a long time and would then not be a cheap option.

However: a substantial proportion of clients may well be much keener than you estimate to apply some oral hygiene, when you have shown them how and they have seen for themselves how much better their pet is for your treatment.

[quote user="David Mills"]Are we expected to believe, hallowed dentists, that these animals treated are somehow 'worse off'?[/quote].

You can believe it or not but animals left with diseased teeth untreated because the veterinary surgeon didn't recognise the disease, or didn't have a clue what to do with it, or knew what should be done but couldn't be bothered, or knew that extraction would be curative but since the tooth was not loose thought it would be too much like hard work to extract it.............. yes, they are certainly worse off.

Why do people wish to invent some "great gulf" between fancy stuff done by specialists on one hand, and a crude "yark 'em all out if I can and clean'em if i can't even though I know the cleaning's pointless". Right in the middle there is straightforward thoughtful competent proper treatment by the GP veterinary surgeon, right there in the real world. Nobody with any wit is advocating fancy clever stuff for every GP case.

Re: Antibiotics for dentals.

David Mills — Thu, 18 Oct 2012 14:25:12 GMT

[quote user="Evelyn Barbour-Hill"]

Sorry, Dagmar, i'm not making you a target, but your post seems to symbolise an attitude and I find it thoroughly depressing.

[/quote]

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Thu, 18 Oct 2012 12:24:37 GMT

[quote user="Dagmar Steele"]

I don't know if it's wise to chime in here, but I'm completely with Clive on this one. I once had a cat in where the tartar had rubbed the cheeks so much they had holes! Do you really think they'd come in for x-rays and stuff? I try to pull whatever I can in these cases and leave the ones in I guess might be still ok-ish. That's not proper dentistry in any way, I am aware of that, but it's still better than doing nothing. If I'd only offer proper dentistry the vast majority of my patients would be left untreated. I always offer to do things right but most owners are not prepared to spend the money. In many cases I see pulling doesn't take long, usually I don't even have to loosen the teeth :-(

[/quote]

Sorry, Dagmar, i'm not making you a target, but your post seems to symbolise an attitude and I find it thoroughly depressing.

Every tooth that's periodontally diseased needs a separate decision made: treat or extract. That decision needs to be made looking at it both as an individual tooth and as part of the whole dentition. Many factors influence the decision, but among those factors ones i want to point out are: –

*the likelihood of adequate oral hygiene in future (which you can further subdivide into type of tooth, animal temperament and of course the nature of the owner. But don't underestimate the owner: many can be motivated to try much harder, once they see how much you have improved the well-being of their pet)

* whether there is any point in keeping the tooth. There's little point in going to great lengths to keep one premolar in the whole mouth. On the other hand it could well be worth it to keep the108 and the 409 even though no other teeth remain on the right side. It needs thought.

What you really should not do is "leave the ones I guess might still be OK-ish" ; except in the emergency case of course. Treat them or take them out, but do something.

People on this forum seem to do all sorts of clever things quite routinely. Your internal medicine discussions make my brain hurt. You seem to find practical ways of dealing properly with all the other bits of the body. Why not teeth?

Re: Antibiotics for dentals.

tess — Thu, 18 Oct 2012 09:05:07 GMT

[quote user="Rachel Perry"]

Why do you use antibiotics for 2-3 days before- I am curious?

[/quote]

2 reasons I guess. The original question was about dealling with the really nasy mouth full of infection. I prefer to get the antibiotics on board asap along with giving pain relief. Secondly the ops list may be too busy to fit in such a major dental at short notice, so it's not unusual to have to arrange it for a day or two's time. I generally start the antibiotics straight away and then book in accordingly. The 2-3 days thing is quite flexible.

Re: Antibiotics for dentals.

Laurence Webb — Thu, 18 Oct 2012 08:57:16 GMT

I voted for 1-2 days because, as Clive said, these are generally chronic problems and I find that a coupld of days antibiotics before a dental wil partially settle things so that the gingiva are less friable so bleed less and are easier to handle. The patients generally feel better for it and if their level of bateraemia is lower then they ought to be a lower anaesthetic risk.

That said, in a case such as he is describing (or one with an abscess or inapetent because the mouth is so bad) I'd get on and do it ASAP as otherwise it will be another year before you get a chance to try to persuade them to have treatment.

Re: Antibiotics for dentals.

Dagmar Steele — Thu, 18 Oct 2012 08:34:23 GMT

Re: Antibiotics for dentals.

Clive Ansell — Thu, 18 Oct 2012 07:29:29 GMT

I feel the same and view these severe cases as salvage procedures, I don't see any point in trying to preserve teeth and full clearance is the way to go. In the case cited above it has taken 4 years to get the dog in, so any further checks or dental care by the owner ain't gonna happen.

Re: Antibiotics for dentals.

Mark Holmes — Thu, 18 Oct 2012 07:08:54 GMT

I try to remove all teeth in these horrid mouths, particularly if the owners are the type who are unlikely to get remaining teeth checked and treated and often if you are taking teeth eitherside anyway one large flap will get the middle one with little extra effort. There seems little point in leaving two teeth in a mouth. Other thàn the lower canines.

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Thu, 18 Oct 2012 00:05:24 GMT

[quote user="Clive Ansell"]

[quote user="Rachel Perry"]

Pulling out loose teeth and scaling what's left: please tell me nobody is still doing that!

[/quote]

? not sure what you mean. That is what happens in 1st opinion practice most of the time; remove diseased teeth and descale +/- polish whats left.

[/quote]

Ah. But "loose teeth' is not the same as "diseased teeth". On the whole, if there are teeth diseased enough to be loose, there will be others which are diseased but not loose (yet), and they need proper treatment too. Do you really remove all diseased teeth?Yeah, extracting them all would be curative, it's true, but how long might that take? it could be very expensive if you charge by time!

Rachel, I'm afraid that my class 2 of veterinary surgeons probably is still pulling and scraping. Or getting the nurses to do it, very likely.

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Wed, 17 Oct 2012 23:56:11 GMT

[quote user="Rachel Perry"]Last week had a jaw fracture case with oesophagostomy tube in place, Saturday vet was concerned about infection of stoma site so gave Convenia![/quote]

Jeeps. Especially when oesophagostomy tubing requires no antibiotic at all. The only ones I've seen get significantly infected are where people have been zealously cleaning, titivating and generally messing about with the stoma.

Re: Antibiotics for dentals.

Evelyn Barbour-Hill — Wed, 17 Oct 2012 23:45:31 GMT

[quote user="james herriot lied"] Cat seen by a colleague yesterday, with obvious upper right cheek abscess and nasty old premolar overlying. Funds ran to pre-GA (18yo cat) bloods, GA, tooth removal, convenia / analgesia; not to rads or bone biopsy.[/quote]

I don't think there's such a gulf in this case. I would have done pretty well the same. Well, to be nitpicking, I would have omitted the convenia as long as drainage was obviously established which I'm guessing from the description it would have been. And i might have radiographed it (no extra charge) simply because I can.

The great gulf lies between veterinary surgeons who understand a bit about oral disease and can do or see what treatment is essential, and those who don't and can't but regard "dentistry" as a nice little extra "profit stream". The latter type would probably think there was something called "gum infection" and regard it as something to be treated with antibiotic.

Re: Antibiotics for dentals.

Clive Ansell — Wed, 17 Oct 2012 22:21:49 GMT

[quote user="Stephen Courtney"]

Clive I think your colleague just didn't want another procedure added to her list. I don't like surprise extras either but if i cry and stamp my feet people just laugh at me...

So what was the outcome - did the doggie get his gnashers fixed?

[/quote]

He did indeed; 4 canines remain, all others in the bin. I did the dental in the end and my colleague agreed to do 2-3pm consults for me (I'll have to take in extra procedures more often )

Seriously, I don't like surprise extras either but occasionally it is necessary.