dental at same time as surgery

Re: dental at same time as surgery

Suzanne Kelly — Sat, 21 Dec 2013 23:47:30 GMT

I'm a GP and cannot believe that someone could think that a 15 minute scale above the gumline and yanking out loose teeth is of any benefit to the animal. As Evelyn said, if some teeth are that bad that they can be removed with little effort, how can any sort of logical mind think that the remaining teeth are without pathology? Animals are expert at hiding chronic pain and there is in my opinion no pain more overlooked by owners and vets than that caused by dental disease. Scaling the teeth above the gumline is cosmetic, it does bugger all for the animal and if not done properly can even cause harm. For me, it takes more than 15 minutes to scale teeth above and below the gumline ( with the proper scaler tip thingy) and to probe them properly and chart them. Another good 15 minutes to take dental xrays as I'm crap at bisecting angles so some of the maxillary teeth take me a few shots to get right. 5 minutes of that is spent effing and blinding about stupid bisecting angles. Extraction times vary, suturing time varies. I don't have anyone to refer things to so I try and do it right the first time around. I was never taught anything at college about teeth either and when I think of what I used to to in the mouth years ago I'm in the horrors. There are loads of good CPD course with wetlabs and ample opportunities to learn.

Re spay and dental, what I do for the charity/ no money ones is explain that I'm going to do a very basic scale ( above and below gumline), probe the teeth and extract the loose ones but be able to give a more accurate estimate of what is required in the future. Most of the time they come back and get the proper procedure done. Some don't but that's life.

Re: dental at same time as surgery

Anthony Todd — Fri, 20 Dec 2013 21:43:42 GMT

Thanks Rob, it sure is comprehensive. I must admit that my recollection is mainly of the thio days. I think there are far fewer problems now.

Re: dental at same time as surgery

Rob Loxley — Fri, 20 Dec 2013 00:30:40 GMT

[quote user="Anthony Todd"]

[quote user="robloxley"]Evidence suggests it is actually the recovery phase.[/quote]

Genuinely. I'd like to see it 'cos I always thought it was induction

[/quote]

http://www.rvc.ac.uk/Staff/Documents/dbrodbelt_thesis.pdf (page 102 has the relevant table)

Re: dental at same time as surgery

Evelyn Barbour-Hill — Fri, 20 Dec 2013 00:13:07 GMT

Could be the original poster wishes to do better than a yark-out-the-obvious-ones followed by a pointless but owner-pleasing sort-of-scale-and-polish.

Re: dental at same time as surgery

Mark Holmes — Fri, 20 Dec 2013 00:01:41 GMT

I would agree Anthony, there are a lots of opinions held with a religious like fervour, based on religious like evidence.

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 23:11:10 GMT

[quote user="robloxley"]Evidence suggests it is actually the recovery phase.[/quote]

Genuinely. I'd like to see it 'cos I always thought it was induction.[quote user="robloxley"]

And you're never wrong either.

And a discussion forum is now not for discussion?

[/quote]

I'd say I was wrong more often than not but my point was that a lot of opinions are not backed up by any evidence and when one [and others, it appears] hold a contrary view, often based on practical experience [see my incorrect view on anaesthetic risk] it's nice, occasionally, to be probably right.

Re: dental at same time as surgery

Rob Loxley — Thu, 19 Dec 2013 22:38:22 GMT

[quote user="Anthony Todd"]I think most of us would agree that induction was the most dangerous phase of anaesthesia so why risk two[/quote]

Evidence suggests it is actually the recovery phase.

[quote user="Anthony Todd"]nine pages of mainly hypothetical huffing and puffing it looks as if you're right.....[/quote]

And you're never wrong either.

And a discussion forum is now not for discussion?

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 21:41:26 GMT

[quote user="Michael Woodhouse"]I said the same in the first reply to this thread.........[/quote]

Yes, and nine pages of mainly hypothetical huffing and puffing it looks as if you're right.....

Re: dental at same time as surgery

Michael Woodhouse — Thu, 19 Dec 2013 21:35:13 GMT

[quote user="Anthony Todd"]

PS Has anyone, anyone at all, had a problem with combining routine surgery with the general old-fashioned perception of a "dental"?

I don't mean the 2 hour procedure some seem to do, but an old fashioned-inadequate-extraction or three or four and a quick ultrasound and polish.

And don't include anaesthetic dramas either; they aren't "dentals" even by even the purists' standards

Anyone?

What nobody?

So why are we banging on about it then?

[/quote]

I said the same in the first reply to this thread.........

Re: dental at same time as surgery

Evelyn Barbour-Hill — Thu, 19 Dec 2013 19:57:22 GMT

[quote user="John Flynn"]EDIT - have just looked back and is periodontal bacteriocidal ultrasonic debridement - is that essentially scaling under the gum?[/quote]

Well – more or less – yes. In the presence of bacteriocidal fluid.

You can do it with that expensive scaler where the water comes out of the tip of the probe; or better in my opinion with the Odontoson otherwise known as the iM3, because the tip vibrates round and round not up and down like a jackhammer (the Odontoson doesn't have a hollow tip but the spray is "focussed" and the water gets carried down to the tip).

[quote user="John Flynn"] i.e. should I just hang up my scaler as doing more harm than good on average?[/quote] I daresay some practices should Depends on your scaler and whether you know how to use it.

[quote user="John Flynn"]What percentage of dental procedures would you reckon in first opinion practice should involve some root planing[/quote]

Dunno, really. 30%? Referring to dogs.

[quote user="John Flynn"]something that I should be looking into in more detail for the sorts of cases I see or not.[/quote]

Something every GP should be aware of and equipped to do in simpler cases. In my opinion. Unless they are prepared to refer to a more expert colleague much more often. Everybody seems to cling to their own dental jobs.

Re: dental at same time as surgery

John Flynn — Thu, 19 Dec 2013 18:44:37 GMT

Not evidence, but happened upon this in a consensus statement from Swedish vets:

"Dental treatments, such as tartar removal, oral sanitation or tooth resection, should not be

performed at the same time as other surgical procedures due to the risk of haematogenous

dissemination of bacteria from the oral cavity to the surgical area"

from: http://svf.se/Documents/S%C3%A4llskapet/Sm%C3%A5djurssektionen/Policy%20ab%20english%2010b.pdf

(an interesting read, i found)

Re: dental at same time as surgery

John Flynn — Thu, 19 Dec 2013 17:46:28 GMT

[quote user="Evelyn Barbour-Hill"]Veterinary Dentistry for the General Practitioner by Cecilia Gorrel, Saunders (part of Elsevier). would be a good start.[/quote]

Thanks. have found this resource online thru library access and found the section on root planing.

I wonder what else there is about dentistry that I don't know that I don't know! (I'm guessing reading the rest of that text would be a good start...)

I think you said what PBUD was in the earlier post (I can't see it while typing this and it's not in that book's index), has it largely replaced root planing in dog/cat dentistry or is it essential to be able to do both for a general practitioner? What percentage of dental procedures would you reckon in first opinion practice should involve some root planing (I can see how it could be indicated in the vast majority I think, but want to make sure I've not got wrong end of stick) - just a rough guesstimate would do fine to give me an idea if this is something that I should be looking into in more detail for the sorts of cases I see or not.

EDIT - have just looked back and is periodontal bacteriocidal ultrasonic debridement - is that essentially scaling under the gum? If so, should I stop doing this with the ultrasonic scaler whose water jet does not come out of the very tip of the probe due to risk of thermal damage? i.e. should I just hang up my scaler as doing more harm than good on average?

Re: dental at same time as surgery

Evelyn Barbour-Hill — Thu, 19 Dec 2013 17:17:12 GMT

[quote user="John Flynn"]

[quote user="Evelyn Barbour-Hill"]actual root-planing on selected surfaces when essential[/quote]

Could you extrapolate or point me in the rigt direction to find out what this is/involves

[/quote]

Veterinary Dentistry for the General Practitioner by Cecilia Gorrel, Saunders (part of Elsevier). would be a good start.

Also Veterinary Dentistry, Wiggs and Lobprise, Lippincott (but for some reason you won't find root planing in the index, although it's in the text all right).

No substitute for a demonstration and practice though.

Essentially it's shaving the exposed surface of the root with sharp instruments ("curettes" ) designed for the purpose, removing calculus, plaque, diseased cementum and even a thin shaving of dentine if that's what is necessary to achieve a smooth surface.

It's pretty laborious. Since mastering PBUD I don't do it in every pocket or every exposed surface any more. But there are types of place where it is essential if you are to achieve any good.

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 17:08:26 GMT

[quote user="Mark Holmes"]I don't recall ever regretting it[/quote]

So you're a "none so far" responder then?

Re: dental at same time as surgery

Mark Holmes — Thu, 19 Dec 2013 16:55:09 GMT

[quote user="Anthony Todd"]

[quote user="John Flynn"]You may consider such an incraese in risk of surgical site infection fairly inconsequential if it existed, but exist it may nonetheless.[/quote]

Trouble is the client doesn't appreciate the theoretical rate of 1% as opposed to 2% except that the fee will go from 100% to probably 180% [or more if it's the current 2 hour "dental"].... And it looks as if the risk may exist although nobody has ever seen it so far.

So the "dental" just won't get done, or the routine op.

And I'm still waiting for just one single report, with the vast number of vets on vetsurgeon.org, of a problem doing the two together.

[/quote] I don't recall ever regretting it

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 16:41:49 GMT

[quote user="John Flynn"]You may consider such an incraese in risk of surgical site infection fairly inconsequential if it existed, but exist it may nonetheless.[/quote]

So the "dental" just won't get done, or the routine op.

And I'm still waiting for just one single report, with the vast number of vets on vetsurgeon.org, of a problem doing the two together.

Re: dental at same time as surgery

John Flynn — Thu, 19 Dec 2013 16:16:14 GMT

[quote user="Anthony Todd"]

So have you had any that you can connect to a concurrent dental?

Think about it too. Here we've got a grotty tooth surrounded by tartar and pus. We remove it and surely the number of pathogens will fall as opposed to leaving the tooth in situ.

Of course you wouldn't do the dental first then delve into the abdomen.

Anyway, see if anyone has had a problem, ever.

[/quote]

I broadly agree with you - I have never knowingly had a problem and combine work in the mouth with other simple soft tissue procedures on a fairly regular basis. So there can hardly be a very high risk associated with this. What I'm not sure on is whether there is an increased complication rate in the soft tissue procedure as a result of this as opposed to staging the procedures - it would seem intuitive enough that there could be.

My point is that if you have a, e.g., 1% complication rate, then if that was doubled to 2% in the face of doing dental at same time (as opposed to doing 2 weeks previously), I don't think I, you or any other average vet would have picked up on this.

You may consider such an incraese in risk of surgical site infection fairly inconsequential if it existed, but exist it may nonetheless.

I think the counter-point being raised is that if you remove the pathogen-base in the mouth and then leave for couple of weeks prior to whatever soft tissue surgery, then that's better than a gap of 5 mins.

Of course, I'm not sure where gingival surgery falls here - is that soft tissue surgery to be delayed or part of the dental procedure

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 15:49:02 GMT

[quote user="John Flynn"]purely based on my recollection of outcomes.[/quote]

So have you had any that you can connect to a concurrent dental?

Think about it too. Here we've got a grotty tooth surrounded by tartar and pus. We remove it and surely the number of pathogens will fall as opposed to leaving the tooth in situ.

Of course you wouldn't do the dental first then delve into the abdomen.

Anyway, see if anyone has had a problem, ever.

Re: dental at same time as surgery

John Flynn — Thu, 19 Dec 2013 15:32:40 GMT

[quote user="Anthony Todd"] If it was at all more risky don't you think some of us would have realised it by now?[/quote]

No. I don't think I would have realised, so not convinced others would have either, purely based on my recollection of outcomes.

Combining the procedures may well double or triple the surigical site infection rate for all I know compared to a staged approach.

Think about it.

What is your soft tissue surgical site infection rate?

What is your serious post-neutering complication rate?

Re: dental at same time as surgery

John Flynn — Thu, 19 Dec 2013 15:29:32 GMT

That's very informative, Evelyn.

I think I roughly followed most of what you said other than:

[quote user="Evelyn Barbour-Hill"]actual root-planing on selected surfaces when essential[/quote]

Could you extrapolate or point me in the rigt direction to find out what this is/involves

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 15:20:15 GMT

PS Has anyone, anyone at all, had a problem with combining routine surgery with the general old-fashioned perception of a "dental"?

I don't mean the 2 hour procedure some seem to do, but an old fashioned-inadequate-extraction or three or four and a quick ultrasound and polish.

And don't include anaesthetic dramas either; they aren't "dentals" even by even the purists' standards

Anyone?

What nobody?

So why are we banging on about it then?

Re: dental at same time as surgery

James Laidlaw — Thu, 19 Dec 2013 15:17:34 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Stop the press[/quote]

Yes, please do. If it was at all more risky don't you think some of us would have realised it by now?

Many of us have been doing a "routine dental" in coonsiderably under 2 hours with apparently no problems and much owner and animal satisfaction.

I think most of us would agree that induction was the most dangerous phase of anaesthesia so why risk two, when we are all waiting for evidence that a "dental" and another procedure concurrently has any greater risk than the single procedure?

[/quote]

Couldn't one also argue that carefully planned and monitored anaesthesia isn't any more risky the second time than the first? How many patients having multiple GA's have serious problems the second, third, fourth time around? How many anaesthetic complications or deaths do you see in practice, and of those how many do you document or audit?

Re: dental at same time as surgery

Anthony Todd — Thu, 19 Dec 2013 14:41:07 GMT

[quote user="Robin Grimmer"]Stop the press[/quote]

Yes, please do. If it was at all more risky don't you think some of us would have realised it by now?

Many of us have been doing a "routine dental" in coonsiderably under 2 hours with apparently no problems and much owner and animal satisfaction.

Re: dental at same time as surgery

Evelyn Barbour-Hill — Thu, 19 Dec 2013 14:16:18 GMT

[quote user="Kate Richardson"]

[quote user="Evelyn Barbour-Hill"]

You all keep talking about "scale, polish and extractions" as if that were all there is to it. What about the teeth that need somewhat more than "scale and polish" but don't need extraction? Do you turn a blind eye to them, or hope for the best, or what?

Very grumpy this afternoon.

[/quote]

Ok so what do you do to teeth that need somewhat more than "scale and polish" but don't need extraction? Excuse my ignorance. I am quite keen on dentistry as a GP, and maybe I need to update my skills, but I am not sure what else one can do in general practice?

[/quote]

All right.

To recognise them would be a good start. And to recognise that a scale and polish will do sweet FA for them.

I won't insist on a chart, or documentation of every tooth, but you might do a bit of probing and exploring and record some of the more significant pocket depths and depths of gingival loss, and of course any hyperplasia and false pocketing. You will radiograph at least the suspect areas unless you have absolutely no facilities for doing so (in which case you'll be considering acquiring some).

Then of course you will be addressing the question of what to do about these problems, and the solutions will include PBUD (periodontal bactericidal ultrasonic debridement) (assuming you have a suitable ultrasonic scaler for the purpose – the cheapest won't do I'm afraid) which I do all the time, actual root-planing on selected surfaces when essential, the simplest of surgery to eliminate or reduce pockets, excision of hyperplasia, consideration of very simple surgery to enhance the gingival coverage of teeth that abut extracted teeth (common example, periodontitis originating interproximal between 108 and 109, you extract 108 as hopeless, the mesial of 109 of course is also in trouble, you mobilise the gingiva that 108 has left behind and suture it snug to 109, another common example would be 408/409), consideration in suitable sites of slightly less simple but by no means esoteric gingival surgery to reduce pockets or improve coverage, inspection for plaque-traps formed by quirks of the individual, consideration of tactical extraction of a small healthy tooth to improve the situation of a more significant neighbour, irrigation, if Doxirobe or an equivalent ever comes back then tactical use of same in selected sites, noting down those teeth that are compromised but will retain periodontal health with the aid of periodontal hygiene and to which the owner must therefore pay particular attention, giving advice and instruction in oral hygiene to the owner that is tailored to the particular patient and the particular owner, repeat examinations at suitable but frequent intervals to re-assess periodontal health and any problems in oral hygiene..................

Not an exhaustive list but the thoughts that spring immediately to mind.

Re: dental at same time as surgery

Kate Richardson — Sat, 14 Dec 2013 20:56:11 GMT

[quote user="Evelyn Barbour-Hill"]

Very grumpy this afternoon.

[/quote]

And why were you grumpy this afternoon?