Small Animal Dentistry.

Re: Small Animal Dentistry.

John Flynn — Fri, 26 Apr 2013 20:02:38 GMT

[quote user="Evelyn Barbour-Hill"]

Naturally. Who suggested extracting the recently fractured one?

[/quote]

This has been suggested to me as the appropriate treatment in the absence of endodontic facilities - I may have misunderstood in which case we are in full agreement after all!

[quote user="Evelyn Barbour-Hill"]You've reached an awful lot of conclusions from your single anecdote[/quote]

The anecdote was only an illustration and I have no firm conclusions, merely a healthy skepticism on the necessity of intervening with every fractured upper canine with pulp exposure in dogs and cats, based on cases I've seen over the years without apparent problems. I will be happy to be convinced otherwise.

[quote user="Evelyn Barbour-Hill"]Maybe you should have treated the cat yourself.[/quote]

I felt that there could be a lower premolar that may require extraction, this required radiographs in my opinion and I felt that referral to a competent dentist with superior facilities in this patient was worthwhile. I fully support the notion that dental radiography facilities are worthwhile (they're on the list and no doubt will get to the top eventually), particularly in cats, and I would rank them ahead of many other "luxury" items such as an automated haematology machine, a tonopen etc.

[quote user="Evelyn Barbour-Hill"]I'd agree it's impossible to do a dental procedure for under £100. Like it's impossible to do an orthopaedic procedure under.......... what? Or impossible to do "a work up with bloods and urine" for under.......... some figure. Or impossible to radiograph the chest properly for under......... some other figure.[/quote]

I disagree here, but again it's nothing personal against dentistry. For instance, I'm repeatedly told that distal radial/ulna fractures in juvenile toy breeds don't heal reliably with splinting - in the absence of any literature to that effect and the cases I've personally seen, I beg to differ.

Comparing with orthopedics is interesting though as I have a simliar approach, i.e. no matter what the deformity or how bad the radiographs may look I treat the patient not the radiographs. I don't do corrective osteotomies on every angular limb deformity, recommend hip replacement on every osteoarthritic hip I see. If the patient does not appear clinically bothered by the radiographic pathology, then I let it be; I don't see why I should approach dentistry differently? Do we have a reason to believe that non-apparent tooth pain is worse than non-apparent joint pain? Should I do a dorsal laminectomy on every patient with lumbosacral stenosis - I mean surely that must hurt if you look at it on MRI?

[quote user="Evelyn Barbour-Hill"]wouldn't it be negligent to treat a broken bone without radiography?[/quote]

Not in my opinion - no. I have done this on a number of occasions (though I admit I'm struggling to remember doing this in a cat / dog other than maybe an untreated palpable pedal bone fracture or something).

Re: Small Animal Dentistry.

James Laidlaw — Fri, 26 Apr 2013 16:31:41 GMT

None of my patients have ever said "ow" or "I'm in pain"... Maybe I need to stop using pain relief.

Ever tried probing a fractured tooth with exposed pulp? Or tapping on it?

Lot's of problems are easier to deal with given time, that doesn't mean we neglect them to make our job easier - the vow is to do the best for animals under our care, not to make our jobs as "easy" as possible. Everything stops bleeding eventually. That doesn't mean I wait to see if it stops naturally with clotting or just as naturally (but prognostically less favourably) by running out of circulating blood volume.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Fri, 26 Apr 2013 15:28:45 GMT

[quote user="John Flynn"](I find a canine with periodontal disease easier/quicker/cheaper to extract than a recently fractured one with healthy periodontal attachments).[/quote]

Naturally. Who suggested extracting the recently fractured one?

[quote user="John Flynn"]t all depends what you think is "necessary". I often take the view of "necessary" to get eating again, in which case I do not feel that extraction of the canine fitted this.[/quote]

You've reached an awful lot of conclusions from your single anecdote, mostly on the logic of speculation and guesswork . Maybe you should have treated the cat yourself.

[quote user="John Flynn"]As an illustration, a Pomeranian with stable congestive heart failure (it that's not an oxymoron, but you know what I mean) came in last week as it wouldn't eat and the owner was concerned that it wouldn't take its pimobendan etc. It took significantly less time than to type this post to identify a loose and painful incisor and remove it and administer a long-acting amoxicillin injection; the dog not only returned to eating, but ate better than it had for perhaps a couple of months.[/quote]

Which is exactly what I would have done (but without the antibiotic). Um, what of it?

[quote user="John Flynn"]A prominent veterinary dentist told a student that it was negligent not to use dental radiography and impossible to do a dental procedure for under £100. That's not really going to help that student help pets where the budget is less than this is it?[/quote]

I'm not going to get into the this that or the other is negligent argument. (I've heard that some idiot surgery lecturer tells his students that catgut is negligence. On the other hand, wouldn't it be negligent to treat a broken bone without radiography?) . However, I doubt if said prominent veterinary dentist was referring to something like your Pomeranian above.

I'd agree it's impossible to do a dental procedure for under £100. Like it's impossible to do an orthopaedic procedure under.......... what? Or impossible to do "a work up with bloods and urine" for under.......... some figure. Or impossible to radiograph the chest properly for under......... some other figure. What does your student do to help pets that need those things doing? There are ways and means, are there not? With always the possibility of simply doing the job and not charging full whack.

Re: Small Animal Dentistry.

John Flynn — Fri, 26 Apr 2013 08:35:19 GMT

[quote user="Evelyn Barbour-Hill"]I'd call lowgrade grumbling toothache a clinical problem.[/quote]

And you may convert me yet to this school of thought, but I'm not there yet. If sufficiently low grade that the dog/cat does not appear to favour prehending/chewing with the other side of the mouth and firm palpation/probing around the tooth does not elicit any signs of pain then I'm not sure this is invariably a big enough problem to necessitate intervention.

[quote user="Evelyn Barbour-Hill"]As clients do. With many diseases – mammary tumours for instance.[/quote]

I can't think of a better analogy off-hand, but I don't think an analogy with mammary tumours is helpful (and don't want to end up in an aside on treatment of mammary tumours also!)

A mammary tumour is non-painful (IMO) to begin with but at risk of being/becoming malignant and becoming harder to deal with the longer it is left alone.

A fractured canine with pulp exposure, but without clinically-apparent signs or pain, is potentially a source of pain which is not so likely to result in life-limiting disease; it may (though does not always appear to IME) lead to more severe (but usually local) disease later on at which point it may be easier to deal with rather than harder (I find a canine with periodontal disease easier/quicker/cheaper to extract than a recently fractured one with healthy periodontal attachments).

[quote user="Evelyn Barbour-Hill"]If the symphysis instability had been present for 14 years, following non-healing of the original separation, it would have been of no significance. There must have been something else causing it to separate recently or the veterinary surgeon would probably not even have troubled to wire it.[/quote]

I personally speculate that this was mostly down to the overzealous oral administration of diltiazem (so I can blame the cardiologist for recommending that, right? ), possibly in a cat with a weakening mandibular symphysis due to the previous injury, an unskilled dental procedure a year previously and the more recent renal insufficiency. Irrespective of the cause, I was contented that this fitted the clinical picture (pain on palpation of cranial mandible and nowhere else; history consistent with oral pain; otherwise stable systemic disease). Wiring it did seem to resolve the problem (albeit there was a lag time of a few days).

[quote user="Evelyn Barbour-Hill"]Sorry, how much of that 1.5 hours was the "extra" time to extract the canine? What were the radiographic findings? The veterinary surgeon (competent, so fully aware of the undesirability of unnecessarily extending anaesthetised time in this patient) must have decided to extract that tooth on the basis of radiographic findings that indicated extraction. [/quote]

I don't have that information to hand, but I was advised that, as there was no periodontal disease in the "offending" canine that it took quite a while to remove it gently via a flap. There were changes in its tooth root on radiography (not that I think radiography was required to predict that!) Radiography of the remaining teeth was unremarkable as I remember it. Knowing how much time it takes to wire a jaw, and being told how quick it is to do dental radiographs in a cat, I suspected that a substantial part of the anaesthetic involved removal of the (apparently non-painful) canine. The vet in question also advised the owner to ask me about getting erythropoietin for the cat; as it had a PCV of 35% last time I'd checked, and the PCV he'd taken was maybe 22% in a cat anaesthetised with midazolam/ketamine/buprenorphine (drugs that could make any cat look anaemic on PCV), I wouldn't describe him as omnicompetent, though I feel a good dental surgeon.

[quote user="Evelyn Barbour-Hill"]Perhaps the procedure did stick to the necessary pathology. [/quote]

It all depends what you think is "necessary". I often take the view of "necessary" to get eating again, in which case I do not feel that extraction of the canine fitted this.

I think there is a law of diminishing returns when it comes to dental intervention.

Both the benefit:cost and benefit:risk ratios decrease with further intervention in many situations. That's not to say that there may not still be a benefit, just that it becomes a relatively smaller benefit for a relatively bigger cost/risk. I don't think that the benefit:cost of removing an apparently non-painful fractured canine with pulp exposure is high enough for many people to consider it worthwhile.

As an illustration, a Pomeranian with stable congestive heart failure (it that's not an oxymoron, but you know what I mean) came in last week as it wouldn't eat and the owner was concerned that it wouldn't take its pimobendan etc. It took significantly less time than to type this post to identify a loose and painful incisor and remove it and administer a long-acting amoxicillin injection; the dog not only returned to eating, but ate better than it had for perhaps a couple of months. A GA and more detailed dental assessment and treatment would certainly have been indicated, but were they essential? Dentistry, like anything else, can be done to degrees and I often feel that the more that is done, the less and less that extra effort becomes rewarded clinically. Don't get me wrong, I think it's great to do the best job possible with the resources at hand and for some that will mean extremely detailed dental assessment and work indeed - there's nothing wrong with that. However for a large number of patients it means doing a quick and cheap job and suggestions such as dental radiography is essential (I've even heard it suggested that it's negligent to try to perform any dental procedure without such facilities) are detrimental if they result in less, albeit suboptimal, beneficial procedures being done.

A prominent veterinary dentist told a student that it was negligent not to use dental radiography and impossible to do a dental procedure for under £100. That's not really going to help that student help pets where the budget is less than this is it?

Re: Small Animal Dentistry.

John Flynn — Fri, 26 Apr 2013 07:19:25 GMT

[quote user="James Laidlaw"]

[quote user="John Flynn"]Started showing signs of oral pain and had obvious periodontal disease etc a year ago: had a "dental" done by another vet which led to clinically-significant renal insufficiency[/quote]

Correlation, causality or coincidence... Not enough information here to make a judgement call!

[/quote]

This was just my assessment based on:

No azotaemia or PUPD up to the day of the (including a pre-op blood sample)
Azotaemia with inadequate urine concentration and no other discernible cause for this less than 3 months after the dental procedure
The owners identifying that the cat was drinking excessively and they thought this started around the time he got his teeth done (but did not attribute any causality themselves).
The risk of renal damage while under GA sufficient to tip renal function over the edge into clinical disease.

The main thrust of my anecdote was simply that the cat lived for 14 years with a broken upper canine without apparent issue and when it was finally removed I don't feel that the time/cost/effort in doing so was worthwhile. Looking at the cat as a whole, I would have left this tooth alone and saved on anaesthetic time. I appreciate this isn't going to resonate with everyone. Equally had it developed a tooth root abscess in that canine in the next 6 months, or indeed developed sufficient pain that it wouldn't eat out of that side of the mouth or on firm palpation of the tooth and surrounding area that it showed signs of resentment, then I would have regretted such a decision - however this had not happened for 14 years, so if I was a betting man I wouldn't think likely to be an issue now.

Re: Small Animal Dentistry.

James Laidlaw — Thu, 25 Apr 2013 22:50:44 GMT

Correlation, causality or coincidence... Not enough information here to make a judgement call!

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Thu, 25 Apr 2013 21:42:47 GMT

[quote user="John Flynn"]Resultant pathology may be an inevitability, but I remain extremely sceptical that there is an inevitable clinical problem as a result of this and I do wonder whether it is possibly misleading to tell clients that this is the case[/quote]

I'd call lowgrade grumbling toothache a clinical problem.

[quote user="John Flynn"] I found clients often concluded that they'd wait until there was a clinically-evident problem with the tooth - such as perceived pain - before intervening,[/quote]

As clients do. With many diseases – mammary tumours for instance. Especially if the message they are taking from the veterinary surgeon is that it is the correct thing to do.

[quote user="John Flynn"]apparently non-painful fractured canine in situ.[/quote]

"Apparently". Yes.

[quote user="John Flynn"]A case in hand:[/quote]

A nice anecdote. Let us look at it.

[quote user="John Flynn"]Fractured a maxillary canine 14 years ago after a fall as well as the mandibular symphysis (the latter was wired, the former ignored). [/quote]

Bad practice, but common, especially 14 years ago.

[quote user="John Flynn"]Started showing signs of oral pain and had obvious periodontal disease etc a year ago: had a "dental" done by another vet[/quote]

Good, one would hope.

[quote user="John Flynn"]so referred to a competent dental vet for detailed oral radiographs. He diagnosed (correctly I feel) that there was mandibular symphyseal instability (presumably a combination of the previous injury to this, thrice daily diltiazem administered religiously by an overzealous owner and perhaps some renal secondary hyperparathyroidism), wired this[/quote]

If the symphysis instability had been present for 14 years, following non-healing of the original separation, it would have been of no significance. There must have been something else causing it to separate recently or the veterinary surgeon would probably not even have troubled to wire it.

[quote user="John Flynn"]wired this and spent a total of 1.5hrs under GA to include full dental radiographs (necessary I felt) and removal of the "offending" canine (unnecessary I felt and not worth the extra anaesthetic time in my view).[/quote]

Sorry, how much of that 1.5 hours was the "extra" time to extract the canine? What were the radiographic findings? The veterinary surgeon (competent, so fully aware of the undesirability of unnecessarily extending anaesthetised time in this patient) must have decided to extract that tooth on the basis of radiographic findings that indicated extraction.

[quote user="John Flynn"]I personally suspect that a shorter procedure sticking to the necessary pathology and ignoring the "offending" canine that had caused no discernible problem for 14 years not would have been preferable.[/quote]

Perhaps the procedure did stick to the necessary pathology.

Re: Small Animal Dentistry.

John Flynn — Thu, 25 Apr 2013 20:29:17 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Michael Woodhouse"]People just don't seem interested when the dog has a broken canine despite being told the theoretical risks etc. [/quote]

Well they ****** well ought to be interested . The resultant pathology is not a theoretical risk, it's a ****** inevitability. . However if the veterinary surgeon is telling them subliminally that it's really not important.......................

[/quote]

Resultant pathology may be an inevitability, but I remain extremely sceptical that there is an inevitable clinical problem as a result of this and I do wonder whether it is possibly misleading to tell clients that this is the case - even when I was less sceptical, I found clients often concluded that they'd wait until there was a clinically-evident problem with the tooth - such as perceived pain - before intervening, and I have euthanased many a dog/cat still with an apparently non-painful fractured canine in situ. I don't think my experience is atypical of the average vet and I haven't seen (or looked to be fair) any published literature that convinces me otherwise.

A case in hand:

16 year old cat with cardiomyopathy (scanned regularly by competent cardiologist) and on diltiazem for last 8 years. Fractured a maxillary canine 14 years ago after a fall as well as the mandibular symphysis (the latter was wired, the former ignored).

Started showing signs of oral pain and had obvious periodontal disease etc a year ago: had a "dental" done by another vet which led to clinically-significant renal insufficiency - worked up and managed and stable now - but did not involve removal of the "offending" fractured canine. No more signs of oral pain for 12 months

Stopped eating recently and history and exam appeared consistent with oral pain as cause of this (always hard to tell in these old cats with multiple pathologies, but pretty confident). Quite a feisty patient, but on conscious exam, there was no pain on firm palpation over fractured upper canine from 14 years ago (I had suspected that this would have been the problem), but there was pain on direct palpation of cranial half of mandible - I suspected probably a FORL or other root pathology in lower premolar and sedated for more detailed exam with view to removing the offending tooth.

On probing, there was nothing obvious at all, and I wasn't going to start pulling teeth for fun, so referred to a competent dental vet for detailed oral radiographs. He diagnosed (correctly I feel) that there was mandibular symphyseal instability (presumably a combination of the previous injury to this, thrice daily diltiazem administered religiously by an overzealous owner and perhaps some renal secondary hyperparathyroidism), wired this and spent a total of 1.5hrs under GA to include full dental radiographs (necessary I felt) and removal of the "offending" canine (unnecessary I felt and not worth the extra anaesthetic time in my view). The cat was, unsurprisingly rather disorientated afterwards for a few days and I had a job convincing the owners to hang in there and not euthanase; I personally suspect that a shorter procedure sticking to the necessary pathology and ignoring the "offending" canine that had caused no discernible problem for 14 years not would have been preferable.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Thu, 25 Apr 2013 19:57:20 GMT

[quote user="Michael Woodhouse"]The big difference, that the vets who have dedicated time, effort and money to become specialised in vet dentistry don't like, is the fact that dogs and cats don't need their teeth.[/quote]

Nope. I do like it. I like some of the other differences from the human too.

[quote user="Michael Woodhouse"]In many cases I have removed every single tooth from a dog or cat and it has gone on to live a perfectly normal, healthy life. They still crunch biscuits.[/quote]

Yep. Me too. When it was the appropriate thing to do.

[quote user="Michael Woodhouse"]I do my best to discuss good dental care with pet owners, but the uptake is poor (I did a poll on here that found most vets who know they should brush their dogs teeth, don't!). Some people bring their pets for bad breath, but most dental issues are picked up at examinations for other things.[/quote]

Exactly so. Which is why I was slightly surprised when someone said that clients came asking for a "dental".

[quote user="Michael Woodhouse"]People just don't seem interested when the dog has a broken canine despite being told the theoretical risks etc. [/quote]

[quote user="Michael Woodhouse"] Evelyn I know you like to play dumb when we say a 'dental' but you know perfectly well it's a scale polish and extractions if needed. [/quote]

Ok, that's a definition at least. So, no assessment of anything (beyond "that's one to extract")? No probing? No looking at the soft tissues? No treatment plans, short- middle- or long-term?

Scale, polish, extractions if needed. Hmm. So what do you do about the teeth for which scaling and polishing is not sufficient, but extraction is nowhere near indicated?

For instance, the dog's canine with sound periodontium except for a deep narrow defect in the gingiva down the buccal side? The canine with apparently sound periodontium until you probe the palatal side and find a narrow pocket 8mm deep? The lower carnassial with a 5mm pocket down the distal side of the distal root? The upper carnassial with distal and mesial roots sound but almost complete loss of bone round the palatal root? And i haven't even started on chips and fractures.

Do you take them all out? Frankly, I would doubt the word of anyone who says yes. Some of those would be ****** hard work, traumatic (true meaning) to the patient, traumatic (amateur psychologist's meaning) to the veterinary surgeon, and hideously time consuming.

[quote user="Michael Woodhouse"]It will be coming out after next booster anyway.[/quote]

Not if I have anything to do with it.

Re: Small Animal Dentistry.

James Laidlaw — Thu, 25 Apr 2013 13:41:29 GMT

Once you start using radiographs, it can be quite a revelation seeing what is (or isn't) there under the gingiva that you'd otherwise have no idea about. I agree with normal machines it's a PITA, but a digital unit and probe isn't outside of the affordability of most practices and if you charge properly for the radiographs you'll have a return on investment and more info for yourself and your clients. With digital it takes me approximately 20-30 seconds to get decent x-rays of a tooth or area of the jaw that I'm happy with.

Re: Small Animal Dentistry.

Michael Woodhouse — Thu, 25 Apr 2013 13:14:51 GMT

The big difference, that the vets who have dedicated time, effort and money to become specialised in vet dentistry don't like, is the fact that dogs and cats don't need their teeth. In many cases I have removed every single tooth from a dog or cat and it has gone on to live a perfectly normal, healthy life. They still crunch biscuits.Very different to the demands of human patients on their teeth.

I do my best to discuss good dental care with pet owners, but the uptake is poor (I did a poll on here that found most vets who know they should brush their dogs teeth, don't!). Some people bring their pets for bad breath, but most dental issues are picked up at examinations for other things.

The majority of mouths that I get my hands on have gingivitis, tartar and smelly breath. People just don't seem interested when the dog has a broken canine despite being told the theoretical risks etc. Evelyn I know you like to play dumb when we say a 'dental' but you know perfectly well it's a scale polish and extractions if needed.

We have flexible, intra-oral films but just for use with the normal x-ray generator. It's a PITA as they are practically opposite ends of the surgery so I very rarely do so.

I have to say that I remove a lot more teeth than I ever used to. If there is significant gingival regression, cracks etc then I take them out. Yes they could maybe be saved, but the follow up at home will not be there. It will be coming out after next booster anyway.

Re: Small Animal Dentistry.

bob lehner — Thu, 25 Apr 2013 12:48:25 GMT

[quote user="Evelyn Barbour-Hill"]You don't have to have a dental radiography unit, just the right size films and the means to process them (very cheap if you wish it so)[/quote]

Yes indeed, I'm well aware of that - sadly it's the lack of any such facility that is usually evident.

Well at least if a VH has the right equipment to do dental x-rays there is a likelihood that it will be used increasingly - surely better than not even having the equipment ?

It's all down to the enthusiasm/motivation/ability of the clinicians - you can say the same about any other toys - scanners/ecg/endoscopes/orthopaedic kit or whatever.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Thu, 25 Apr 2013 11:38:33 GMT

[quote user="bob lehner"] visit many practices and it is pretty uncommon to find one where dental radiography is available [/quote]

What do you mean by "dental radiography is available"? You don't have to have a dental radiography unit, just the right size films and the means to process them (very cheap if you wish it so)

[quote user="bob lehner"]SA VHs are required to have dental radiography - but I suspect even here it is often an under-utilised facility unless at least one clinician is unusually keen on dentistry.[/quote].

You are talking about the PSS? Which illustrates one of the things wrong with the PSS: you've got the "facility" so you've ticked that box, but you may still be doing cash-cow "dentals".

Re: Small Animal Dentistry.

Peter Southerden — Thu, 25 Apr 2013 11:31:15 GMT

[quote user="David Mills"]

[quote user="Nicola M"]I think I'm just trying to ascertain whether this is common place in first opinion practice or limited to slightly (!) old-fashioned practices[/quote]

It is very common indeed IME. It might be something for a poll on here. I'd estimate 80-90% of practices don't use dental radiography routinely. There is a cost-benefit analysis to be made, and that includes time. In some places where I've worked (anecdote) that have had radiogrpahy people have spent 60m getting images, chatting about what they were going to do, then doing about 20-30m extractions which, in those cases, were obvious extractions. That's all on the clients time. Whether it's right or not, who knows. I haven't seen any convincing evidence to back up the statement that dental radiography is essential, nowhere near in fact.

This will likely open a can of worms, but the vast majority of dental work is extractions. And possibly so it should be - because a skilful extraction is better than a botched repair or similar. In first opinion practice the vast majority of extractions are straightforward. Dentistry is not orthopaedics for the mouth.

[/quote]

Hi David

We usually take a straw poll during the courses we run and I think that your estimate of the proportion of practices that have dental radiography facilities is about right. This is changing quite quickly though.

It takes about ten minutes to take full mouth radiographs in a cat (ten views) using a modern digital system. Frank Verstraete (UC Davis) published a paper showing that there was clinically important information not evident from a clinical examination in about 50% of these cases and that because of this full mouth radiography is justifiable in all feline dentistry procedures. He published a similar paper that related to dogs. Many of the indications for treatment are subgingival - endodontic disease, tooth resorption etc. In addition to this even where it is evident from a clinical exam that a tooth should be extracted x-rays are important to plan and ensure that an extraction is properly informed. Do you know what dilacerations is? Do you know how it would change your extraction technique? Do you know which teeth are likely to have more than the normal number of roots which will obviously affect the procedure? Do you know in both cats and dogs the extent of conditions like tooth resorption which will affect what you need to know. Are you confident that you have performed all of your extractions completely and that there are no root remnants which may cause problems in the future?

I am not sure that the choices that we have are between skilful extraction or botched repair. I'm not sure what you mean by a botched repair. Surely we should be making good clinical decisions based on an reasonable level of knowledge and then carrying out the appropriate treatment backed by the necessary clinical skills. Some extractions are straight forward but there are plenty that aren't. In the human field straightforward extractions are carried out by dentists who train for five years. Complicated extractions (third molars for example) are carried out by maxillofacial surgeons who are dual qualified (degrees in dentistry and medicine). I am not suggesting that we should replicate this but that it suggests that things may not be as simple as you think. Of course dentistry is not orthopaedics of the mouth - what ever that means, but it is often oral surgery which requires a specific skill set - different but nonetheless important for our patients.

Kind regards

Peter

Re: Small Animal Dentistry.

bob lehner — Thu, 25 Apr 2013 09:54:35 GMT

[quote user="David Mills"]It might be something for a poll on here. I'd estimate 80-90% of practices don't use dental radiography routinely. [/quote]

Agree with this.

I visit many practices and it is pretty uncommon to find one where dental radiography is available - or even if the facilities are there, frequently under-used.

SA VHs are required to have dental radiography - but I suspect even here it is often an under-utilised facility unless at least one clinician is unusually keen on dentistry.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Wed, 24 Apr 2013 18:13:50 GMT

[quote user="Evelyn Barbour-Hill"]My feeling is that this is still rather commonplace in general practice but is gradually shifting to the "slightly old-fashioned". [/quote]

PS: A Thought.

Partly this is a demonstration of the long lag time in practice for almost any improvement, due to the Senior Partner Effect. (Which is not all bad, since it also slows down the rush into detrimental developments.)

But I fear that in the case of dentistry it is also due to some younger, energetic, entrepreneurial-spirited practice owners who view "dentals" as a fine "income stream".

In my opinion, of course

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Wed, 24 Apr 2013 17:48:55 GMT

[quote user="Nicola M"] I completely agree with you questioning: "What is a 'dental' anyway?" I think the term should be banned as it severely undervalues the care,time and expertise that is required in dentistry! The reason I used it ( in quotation marks to hopefully indicate that i did not agree with the term) is that you do get a fair number of clients wanting to book their older pets in for what THEY would call a "quick dental" once the pet has stinky breath and a few of the teeth are falling out. Whether its through poor client training (on the practice's side), client finances or these are casual clients that just turn up when they can see a problem. It's certainly not the preventative, lifelong approach to dentistry but unfortunately it does happen a lot. I think I'm just trying to ascertain whether this is common place in first opinion practice or limited to slightly (!) old-fashioned practices. Unfortunately, like with most things that have a preventative arm to them, it only works if the whole practice is on board with it.

[/quote]

My feeling is that this is still rather commonplace in general practice but is gradually shifting to the "slightly old-fashioned". And yes, your final sentence is utterly true.

[quote user="David Mills"] In some places where I've worked (anecdote) that have had radiogrpahy people have spent 60m getting images, chatting about what they were going to do, then doing about 20-30m extractions which, in those cases, were obvious extractions. That's all on the clients time.[/quote]

That depends on whether you charge it by time or not............... Well, anyway, though I don't doubt your anecdote, I think it a little unrepresentative and possibly misleading.

[quote user="David Mills"]This will likely open a can of worms, but the vast majority of dental work is extractions. And possibly so it should be - because a skilful extraction is better than a botched repair or similar.[/quote]

True, so if extraction is all you know how to do................

[quote user="David Mills"]In first opinion practice the vast majority of extractions are straightforward.[/quote]

Hm. Just look back at the original post, for instance. Cats' teeth severely affected by FORL are common problems in practice and are not straightforward.

And what do you do with the teeth that have a bit more wrong than just gingivitis and some heavy calculus, but haven't nearly enough wrong to warrant extraction? What do you do then? Just leave 'em like that (as we used to do forty years ago)? Extract them all regardless? You'd spend an awful lot of your working life extracting teeth (and on the client's time, too? )

[quote user="David Mills"]Dentistry is not orthopaedics for the mouth.[/quote]

Re: Small Animal Dentistry.

David Mills — Wed, 24 Apr 2013 13:13:22 GMT

[quote user="Nicola M"]I think I'm just trying to ascertain whether this is common place in first opinion practice or limited to slightly (!) old-fashioned practices[/quote]

Re: Small Animal Dentistry.

Nicola Cole — Wed, 24 Apr 2013 12:54:46 GMT

I completely agree with you questioning: "What is a 'dental' anyway?" I think the term should be banned as it severely undervalues the care,time and expertise that is required in dentistry! The reason I used it ( in quotation marks to hopefully indicate that i did not agree with the term) is that you do get a fair number of clients wanting to book their older pets in for what THEY would call a "quick dental" once the pet has stinky breath and a few of the teeth are falling out. Whether its through poor client training (on the practice's side), client finances or these are casual clients that just turn up when they can see a problem. It's certainly not the preventative, lifelong approach to dentistry but unfortunately it does happen a lot. I think I'm just trying to ascertain whether this is common place in first opinion practice or limited to slightly (!) old-fashioned practices. Unfortunately, like with most things that have a preventative arm to them, it only works if the whole practice is on board with it.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Wed, 24 Apr 2013 12:13:20 GMT

[quote user="Nicola M"]I really hope this does not sound rude (as things can sometimes when written down)-it is a genuine question and not to get people's backs up! What is the best thing to do if you work in a practice that does not have dental radiography and you are not the boss (therefore not in a position to change the situation)? Most of the clients would still expect 'dentals' and would not expect to have to be referred for one. I would also think that the boss would not be expecting you to refer them (except in specific circumstances) as they are obviously happy with the set up. Are there still a high proportion of practices out there that do not have dental radiography? Presumably they would just go about it as practices would have done before radiography became more common? Would anybody refuse to do a dental procedure if radiography was not available (I am talking treatment of older dog/cat mouth not specific things like fractured canine in a young dog)?

[/quote]

Tell the boss to do his own "dentals" if he's happy with the set up? .

Hmm, p'raps not. Just do the best you can, I guess.

What is a "dental" anyway?

I'd rather disagree with this, though;[quote user="Nicola M"]Most of the clients would still expect 'dentals'[/quote]

Re: Small Animal Dentistry.

Nicola Cole — Wed, 24 Apr 2013 11:59:10 GMT

I really hope this does not sound rude (as things can sometimes when written down)-it is a genuine question and not to get people's backs up! What is the best thing to do if you work in a practice that does not have dental radiography and you are not the boss (therefore not in a position to change the situation)? Most of the clients would still expect 'dentals' and would not expect to have to be referred for one. I would also think that the boss would not be expecting you to refer them (except in specific circumstances) as they are obviously happy with the set up. Are there still a high proportion of practices out there that do not have dental radiography? Presumably they would just go about it as practices would have done before radiography became more common? Would anybody refuse to do a dental procedure if radiography was not available (I am talking treatment of older dog/cat mouth not specific things like fractured canine in a young dog)?

Re: Small Animal Dentistry.

Peter Southerden — Wed, 24 Apr 2013 11:14:55 GMT

Hello

As has already been mentioned we do run various dentistry and oral surgery courses in our purpose built lecture and wetlab facilities. We can do practice visits for training but I don't think we can teach as much as we can in our own facilities. There is a feline dentistry course planned for later in the year. You can find the details on our referral web site www.eastcottreferrals.co.uk/. We also welcome vets coming to see practice with us, either for first opinion or referral work, though obviously we can only take one at a time. By all means drop me a message or email and we can sort that out for you.

Extracting cats teeth with tooth resorption (TR or FORL) is challenging. As well as gaining the necessary surgical skills and techniques it is important to have good instruments and equipment. Intraoral radiography is essential in order to evaluate a tooth prior to extraction, to plan the extraction procedure and to ensure that the tooth has been extracted properly post operatively. Though the investment in equipment can seem significant, it is an investment that will pay for itself very quickly.

Let me know if there is anything that I can help you with.

Best wishes

Peter Southerden BVSc MBA DipEVDC MRCVS

European and RCVS Recognised Specialist in Veterinary Dentistry

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Tue, 23 Apr 2013 23:02:44 GMT

[quote user="GrooveJet"] I am hopeful that if I am able to demonstrate a growing expertise in the field, it will be easier to source funding for better equipment.[/quote]

The trouble is, of course, that if you are struggling with, er, suboptimal instruments it's hard to acquire a growing expertise. Anyway, I'd suggest for luxators either a set of original Svenska ones or a set of the new stubby handle ones Kruuse brought out this year. For elevators if you want elevators, look at the very shorthandled set from Vet Instrumentation, or the ones (confusingly named "Extraktors") from Accesia in Sweden. Some people like "winged" elevators, others hate them. It's a personal thing.

FORL teeth. Well, Xray first so you know what you are trying to do. Divide all the teeth in question into individual single-root units, of course. Commence as any extraction – which might mean a "closed" extraction or might mean going for an open ("surgical") one straight away. If the tooth breaks, turn it into a surgical extraction. That's my approach. There's also a lot to be said for the approach of: we know at least some of the roots in this row are going to require a surgical removal in the end – so let's make a single flap for the whole row and do them all surgically anyway.

"Burring out" roots is a big no-no, as you know-know. BUT: if a root is thoroughly ankylosed, half resorbed and replaced with bone, all you can do is bur out the bone/dentine mixture. What's the difference? Only one of degree. And if a portion of root is thoroughly ankylosed, being resorbed and replaced, there is nothing wrong with leaving some of that dentine behind, as long as it's well buried with no spikes sticking up.

No magical hints or tips for this one I'm afraid, apart from "get good at doing flaps". There's no substitute for watching somebody do it then doing it yourself under supervision.

Re: Small Animal Dentistry.

Miriam Lodewyks — Tue, 23 Apr 2013 19:36:25 GMT

Yes, I have the afore-mentioned tools at my disposal. Probably not the best quality equipment, but one makes do. I am hopeful that if I am able to demonstrate a growing expertise in the field, it will be easier to source funding for better equipment. Can you perhaps recommend a brand of luxators and elevators that are worth investing in? Going back to the original post though: any actual advice, hints, tips on how to actually make dentistry a little easier for those of us who are trying their best... would be much appreciated.

Re: Small Animal Dentistry.

Evelyn Barbour-Hill — Tue, 23 Apr 2013 16:25:01 GMT

[quote user="GrooveJet"]Thank you Evelyn. I have basic hand tools, a scaler and an old but effective burring machine with cutting and round burrs. If I shouldn't be removing FORL teeth, then what do you propose I do? Referring to a specialist is mostly out of the question on grounds of cost... one reason I'd like to be able to offer a better service myself. PS. was listening to the radio when I signed up and "Groovejet" was on... Simple. :-) Will give Pete Southerdon a call I think.

[/quote]

Umm.... not sure what you mean by a burring machine. Not an airdriven unit with low- and high-speed handpieces I presume? No matter, you can do good work with a proper electric dental unit. You have some tapered fissure burs and some round burs (of various sizes?) by the sound of it. You do discard the bur after a couple of uses, don't you?

Have you a couple of sizes of good quality periosteal elevator? Have you some small size luxators which you keep sharp? Have you some good small veterinary extraction forceps? Have you a means of radiographing the teeth? Ok, you can do cats' teeth and you can extract (or rather, remove, would be a better word) FORL teeth using gingivoperiosteal flaps if necessary.