New Practice Standards

Re: New Practice Standards

Colin Cameron — Fri, 23 Apr 2010 18:34:16 GMT

can this discussion get back to the original question about the PSS dictating clinical practice as well as premises, equipment and facilities etc. It seems to me that when the public see that when a surgery is accredited on the scheme they assume that the whole set-up reaches certain standards including clinical practice. This may not be the original intent but it is a common perception. However, any practice wishing to join the scheme would, I assume, be working to high standards anyway and would probably be doing things to current acceptable practice. lets all modernise to high standards but keep thing simple where more complex procedures have no real benefit. The arguments will then float off into the ether and we can get on with life guiltless!!!

Re: New Practice Standards

Colin Cameron — Fri, 23 Apr 2010 18:16:31 GMT

for teth read teeth

Re: New Practice Standards

Colin Cameron — Fri, 23 Apr 2010 18:15:57 GMT

just noticed that it should be bur

Re: New Practice Standards

Colin Cameron — Fri, 23 Apr 2010 18:13:31 GMT

A minor point but surely we trim teth with either a burr or a diamond cutting disc which is inserted ont the handpiece. How do you trim teeth with the actual handpiece itself? Hmmm! ( Tongue, of course, firmly in cheek !)

Re: New Practice Standards

Anthony Todd — Fri, 23 Apr 2010 02:04:45 GMT

[quote user="Evelyn Barbour-Hill"]Try 957471(flat fissure plain cut ISO size 010, RA) or 957463 (same but cross cut).[/quote]

Thanks for the info.; will get some in

Re: New Practice Standards

Evelyn Barbour-Hill — Thu, 22 Apr 2010 16:03:46 GMT

Try 957471(flat fissure plain cut ISO size 010, RA) or 957463 (same but cross cut).

But don't blame me if Kent have had one of their change-all-the-code-numbers upheavals recently.

Re: New Practice Standards

Anthony Todd — Thu, 22 Apr 2010 00:37:45 GMT

[quote user="Michael Woodhouse"]Thankfully not[/quote]

I'm still waiting for someone who clips rabbits' teeth to document a subsequent problem, there must be at least one, somewhere, surely.

I take on board the advice regarding cutting discs and burs [now spelt correctly]. Can anyone give me the specific identification of the bur they recommend, we'll get some in.

Kent Express have the whole human range at a sensible price but I need a reference code.

Re: New Practice Standards

Michael Woodhouse — Wed, 21 Apr 2010 23:46:25 GMT

[quote user="Anthony Todd"]Michael, you must have done a lot of tooth clipping.[/quote]

Thankfully not. There is one rabbit in the practice we see every couple of months that get its teeth clipped.Have done a few others over the years including at various practices as a student, including my own when unqualified!

[quote user="Anthony Todd"]How many do you recall suffering any post-clip complications of any nature [apart from catching a lip in the clippers....]?[/quote]

None. Ours used to go to the bowl to eat straight afterwards. If it was in agonising dental pain I can't see that happening (I've has sleepless nights from toothache myself).

Re: New Practice Standards

Anthony Todd — Wed, 21 Apr 2010 11:30:18 GMT

Michael, you must have done a lot of tooth clipping.

How many do you recall suffering any post-clip complications of any nature [apart from catching a lip in the clippers....]?

Re: New Practice Standards

Gillian Mostyn — Wed, 21 Apr 2010 10:38:39 GMT

[quote user="Michael Woodhouse"]We have no mechanical means of grinding teeth - it's clipping them or nothing. You propose I 'refer' the bunny for this procedure?[/quote]

If you don't have a dental handpiece, how are you doing dogs and cats??

It is irrelevant though - if you don't have a dental machine at all the PSS is unlikely to be something you are going to apply for.

Re: New Practice Standards

Anthony Todd — Tue, 20 Apr 2010 23:56:35 GMT

Here's another quote from a colleague of mine, more elegant than my replies.

"I have always just clipped them with a nail clippers and never (repeat never) had any problem except once catching a bit of lip in the guillotine clipper. However, current theory is that this is barbaric/dangerous/cruel etc and I have just asked one of my vets and she does them fully conscious with the dental burr ' so they don't shatter'. Still, she does hamster teeth with the clippers! It's another one you won't win. Ethics are based on culture and culture changes so so do ethics. Culture does not however change logically. "

Surely we can't all have been denying the terrible consequences of our continued barbarism?

Re: New Practice Standards

Michael Woodhouse — Tue, 20 Apr 2010 23:55:46 GMT

[quote user="Evelyn Barbour-Hill"]I think the onus should be on people who "clip" to answer this question: why do it at all when you can trim the teeth much better, without causing damage, in only five minutes, with a dental handpiece?[/quote]

erm - we don't all have a dental handpiece!

I had rabbits as a child and we never took them to the vets. Had 1 which we clipped its teeth ourselves.

We have no mechanical means of grinding teeth - it's clipping them or nothing. You propose I 'refer' the bunny for this procedure?

Re: New Practice Standards

Evelyn Barbour-Hill — Tue, 20 Apr 2010 19:52:11 GMT

[quote user="Anthony Todd"]So everyone is using a diamond disc in the handpiece then?[/quote]

You can use a diamond disc once you are skilled and practised and you are sure of your nurse. Until then, do it with a tungsten carbide bur (not burr (pedant! ))...... preferably a new one, but a sharp one anyway. Dribble a little water on with cotton wool for cooling. Use a light touch.

[quote user="Anthony Todd"]Perhaps my crushed and shattered mal-occlused teeth, and those of the other two posters, who claimed never to have had problems have just been lucky, or the splits and chips just grow out for next time.[/quote]

Perhaps so.

Re: New Practice Standards

Ian Mostyn — Tue, 20 Apr 2010 10:18:01 GMT

If you clip them on a regular basis you will damage the crown and probably the root of the tooth as well. You can get a tooth root abscess if you damage the root which can then lead to ostemyelitis. I use a dental burr with a flat end tapered burr on an air driven machine and it is very straightforward. Just get a nurse to hold the rabbit with two hands on the shoulders, you don't need a vice-like grip for most bunnies. In the early stages you can do corrective burring and vastly reduce the frequency of repeat trimming. If you need to clip / trim every 2 - 3 weeks, the incisors need removing. It really isn't a contentious issue amongst rabbit vets / CertZooMed holders, you should never clip incisors.

Whether it should be in PSS? I actually think the PSS would be better setting some minimum standards of care / welfare rather than worrying about paperwork that is the responsibility of other organisations. The PSS doesn't really tell you anything about the standards of care, just about the paperwork / equipment list.

Ian

Re: New Practice Standards

Anthony Todd — Tue, 20 Apr 2010 06:49:51 GMT

[quote user="Evelyn Barbour-Hill"]People do unfortunately persist in referring to a dental handpiece as a "drill".[/quote]

I didn't realise that and as no one has mentioned the bit you put in the end of the handpiece,and, as my teeth used to be drilled with a burr in the handpiece I thought it worth clarifying.

So everyone is using a diamond disc in the handpiece then?

Perhaps my crushed and shattered mal-occlused teeth, and those of the other two posters, who claimed never to have had problems have just been lucky, or the splits and chips just grow out for next time.

Re: New Practice Standards

Evelyn Barbour-Hill — Tue, 20 Apr 2010 00:33:28 GMT

[quote user="Anthony Todd"]Should add that I'm talking about gross mal-occlusion or deformity, not over growth with normal occlusion, which should always be investigated properly.[/quote]

Errrrr.......... if a rabbit's incisors are occluding normally, they can't be overgrown

[quote user="Anthony Todd"]If you are going to use a "drill" I suggest small 10p sized diamond cutting disc rather than drills unless that's what people mean. [/quote].

People do unfortunately persist in referring to a dental handpiece as a "drill". It's jarring, but harmless.

[quote user="Anthony Todd"]

And me too, so there's three who've done loads, so let's hear of these problems 'cos I haven't and nor have they.

Should add that I'm talking about gross mal-occlusion or deformity,

[/quote]

P'raps you've only hacked off a bit, rather than reducing the tooth to a proper level, thus in a way avoiding most risk.

The whole idea of using nail clippers to "cut" a chunk of substance that's extremely hard is a bit silly. And yes, I've done loads like that........... many years ago. Ever done any tiling? It's like expecting to cut a tile with a pair of shears, or maybe a hammer and chisel.

It doesn't cut at all, it just smashes through.

There are gross risks of the fracture lines going into the pulp, or even splitting the tooth longitudinally. If these don't happen, there are still going to be micro-fracture going all over the place and probably involving the pulp. The exact level at which you "cut" is uncontrollable and the surface left is all spiky and jagged.

A little more abstruse, as the clipper smashes its way through, violent shock waves are probably generated up and down the pulp, which (apart from causing pain) may eventually cause a pulpitis that kills the pulp.

It's quite common for me to see rabbits which have had their teeth "clipped regularly" at other practices, either because the owners self-refer or because they have simply moved to my part of the country. So often, one or more of the incisors is actually dead due to the "clipping" injuring the pulp. So often, too, there is, underlying, a big cheek tooth problem that nobody bothered to look for.

I think the onus should be on people who "clip" to answer this question: why do it at all when you can trim the teeth much better, without causing damage, in only five minutes, with a dental handpiece?

Re: New Practice Standards

Anthony Todd — Mon, 19 Apr 2010 14:30:23 GMT

[quote user="Rob Wilson"]At what point does it become part of the remit of practice standards to dictate on our clinical judgement? I have been clipping rabbit's incisors for all my years in practice, at a nominal fee to the owners, and can honestly say I have never had an issue with it[/quote]

Ditto - I've always clipped rabbits' teeth and have never had a problem. Is another quote.

And me too, so there's three who've done loads, so let's hear of these problems 'cos I haven't and nor have they.

Should add that I'm talking about gross mal-occlusion or deformity, not over growth with normal occlusion, which should always be investigated properly.

If you are going to use a "drill" I suggest small 10p sized diamond cutting disc rather than drills unless that's what people mean.

Re: New Practice Standards

Gillian Mostyn — Mon, 19 Apr 2010 10:57:21 GMT

[quote user="Anthony Todd"]By whom and, more importantly, why.[/quote]

By anyone who knows anything about rabbit teeth. As to why - I'm not a 'rabbit expert' by any means but I believe it is because you do a lot of damage to the tooth - above and below the gum - much of which you don't see. Hopefully a specialised rabbit vet can explain more fully......

I agree that PSS shouldn't dictate clinical practice where different opinions exist. But the comparison with being told to use a TPLO for repairing a ruptured CCL is not comparable. Speak to 100 orthopoedic surgeons and you're likely to get a fair few different opinions on which method is best, depending on dog, weight, age, concurrent conditions etc etc etc. Speak to 100 exotics vets and I'd be amazed if you find a single one that says it is OK to clip teeth routinely with nail clippers.

Re: New Practice Standards

Anthony Todd — Mon, 19 Apr 2010 01:38:50 GMT

[quote user="Gillian Mostyn"]clipping rabbit teeth with nail clippers is now considered wrong.[/quote]

By whom and, more importantly, why.

Re: New Practice Standards

Gillian Mostyn — Sun, 18 Apr 2010 23:27:35 GMT

[quote user="Rob Wilson"]Missed the point guys.... it was more about the over-regulation of us by the PSS committee, rather than best practice per-se.[/quote]

Not really. In most cases I disagree with PSS regulation in that it is more about correct paperwork than best clinical practice. In this case, I think it is spot on. There is no debate to be had - clipping rabbit teeth with nail clippers is now considered wrong.

Re: New Practice Standards

Vikki Halliday LLB — Sun, 18 Apr 2010 21:48:55 GMT

[quote user="Rob Wilson"]

Missed the point guys.... it was more about the over-regulation of us by the PSS committee, rather than best practice per-se.

[/quote]

I personally agree with Evelyn on this, I think that to clip teeth with an instrument not designed for the purpose, when drills are available in most practices, is verging on negligent when you clearly appreciate the potential consequences by mentioning fracture lines.

Sure, where a drill is not available, and the tooth has grown to an extent that to not take action will prolong suffering, I could see an argument for using whatever equipment you have available to take the tip off. But to regularly see animals every 6 weeks and effectively fracture their teeth with a relatively blunt, high pressure instrument?

I do think that anyone arguing for retention of routine teeth clipping wants their own incisors done with a pair of pliars first!

Re: New Practice Standards

Robert Wilson — Sun, 18 Apr 2010 20:31:17 GMT

Missed the point guys.... it was more about the over-regulation of us by the PSS committee, rather than best practice per-se.

Re: New Practice Standards

Gillian Mostyn — Sun, 18 Apr 2010 20:10:00 GMT

[quote user="Niall Taylor"]to my mind the risk of soft tissue damage from using a high speed drill conscious, not to mention the stress caused by the noise of the drill far out weighs the "risk" of clipping. [/quote]

I assume from your use of the term 'to my mind' that you haven't tried it? Rabbits react surprisingly little - and it takes only a few seconds to make a very neat, precise cut. You do need a good drill but if you have one, give it a try! You may be surprised.

Re: New Practice Standards

Evelyn Barbour-Hill — Sun, 18 Apr 2010 19:29:03 GMT

[quote user="Niall Taylor"]I've always clipped rabbits' teeth and have never had a problem. Some require treatment every 6 to 8 weeks and to my mind the risk of soft tissue damage from using a high speed drill conscious, not to mention the stress caused by the noise of the drill far out weighs the "risk" of clipping. [/quote]

I simply disagree entirely with your assessment of the relative risks.

Some need doing every 2-3 weeks. Of course, as Rob mentioned, extraction is the best option in the long run.

You wouldn't use a high-speed handpiece. People have tried, and the essential water spray makes the rabbit react violently (not surprising). You use a low speed handpiece, with a nurse holding the rabbit of course, and it takes little time to neatly cut the teeth at exactly the desired line and angle, instead of cracking and smashing them off.

[quote user="Niall Taylor"]What next, as you say - will every rabbit incisor trim have to be performed under GA?[/quote]

No. Why?

Then, there's not much point in continually cutting the incisors, time after time, without at least once examining the cheek teeth and treating them if necessary: cheek tooth malocclusion is probably the commonest cause of incisor malocclusion in rabbits. Deep sedation is fine for examination of the cheek teeth, and usually for treatment too.

Re: New Practice Standards

Evelyn Barbour-Hill — Sun, 18 Apr 2010 19:10:37 GMT

[quote user="mel kavanagh"]

Like most things in this job, it tends to come down to money, How much do you charge to ga a rabbt to clip its teeth? Have to be £70-£80 presumably. iv catheter? can you place and et tube ( i cant)? and repeat every couple of months. I have no clients that would pay for that. ?consider euthanasia as a legitamate tx option? Probably cover costs at £20 but could you take the hassle and stress at that price? given inevitably some will die..

[/quote]

No one is seriously suggesting a GA to cut the incisors. If you wish to be charitable and cut them for a "nominal" charge, why not cut them properly for a nominal charge? I'm not quite sure why a rabbit automatically requires charity treatment anyway, and I have never understood why doing something out of charity means doing it badly.

Deep sedation (no catheters, no tubes) and examination and treatment of the cheek teeth would yes, be over £100. Most rabbit owners accept that when they understand its importance.