Today's Veterinary Technician, July 2017

REHABILITATION TREATMENT OPTIONS FOR PATELLAR LUXATION

BEHAVIOR BECOMING FEAR FREE

DENTISTRY DENTAL DISEASE IN RABBITS

CAREER CHALLENGES IMPROVING CLIENT COMPLIANCE

SURGERY INTERVERTEBRAL DISC HERNIATION

TODAY’SVETERINARYTECHNICIAN | An Official Journal of the NAVC | todaysveterinarytechnician.com | Volume 2, Number 4 | July/August 2017 |

Canine Uveitis RECOGNIZING THE RISKS

1 DOSE: 12 WEEKS OF COMPLIANCE *

VET-RECOMMENDED BRAVECTO TAKES CARE OF KILLING FLEAS AND TICKS FOR 12 WEEKS* WITH JUST 1 CHEW. ®

Nearly 3X longer flea and tick protection than monthly treatments – 12 weeks!1* Fast-acting protection kills 100% of fleas in under 12 hours1,2 Improves client compliance with less frequent dosing1

ORDER PRESCRIPTION-ONLY BRAVECTO® FOR YOUR CLINIC Contact your Merck Animal Health rep or distributor partner.

BRAVECTOVETS.COM *Bravecto kills fleas, prevents flea infestations, and kills ticks (black-legged tick, American dog tick, and brown dog tick) for 12 weeks.

Bravecto also kills lone star ticks for 8 weeks.

IMPORTANT SAFETY INFORMATION: The most common adverse reactions recorded in clinical trials were vomiting, decreased appetite, diarrhea, lethargy, polydipsia, and flatulence. Bravecto has not been shown to be effective for 12-weeks’ duration in puppies less than 6 months of age.

Bravecto is not effective against lone star ticks beyond 8 weeks after dosing.

References: 1. Bravecto [prescribing information]. Madison, NJ: Merck Animal Health; 2014. 2. Taenzler J, et al. Parasites & Vectors. 2014;7:567.

Please see Brief Summary on page 4.

Copyright © 2016 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co., Inc. All rights reserved. US/BRV/1116/0105

TODAY’SVETERINARYTECHNICIAN todaysveterinarytechnician.com

JULY/AUGUST 2017

Editor in Chief Lynne Johnson-Harris, RVT LJohnson@NAVC.com

Editorial Advisory Board Brenda K. Feller, LVT, CVT, VTS (Anesthesia) Animal Specialty Hospital of Florida, Naples, Florida Rosemary Lombardi, CVT, VTS (Emergency and Critical Care) Director of Nursing, University of Pennsylvania Matthew J. Ryan Veterinary Hospital Jeanne R. Perrone, CVT, VTS (Dentistry) VT Dental Training, Plant City, Florida Heidi Reuss-Lamky, LVT, VTS (Anesthesia and Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition) 4 Cats Consulting Belleville, Michigan

CONTACT US

An Official Journal of the NAVC

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CONTENTS

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

todaysveterinarytechnician.com

JULYAUGUST2017

Volume 2, Number 4

PEER-REVIEWED CE Intervertebral Disc Herniation STEPHANIE GILLIAM, RVT, BS, CCRP, VTS (NEUROLOGY)

Intervertebral disc herniation is the most common spinal disease in dogs. This article discusses the pathophysiology, signs, diagnosis, and treatment of this condition, as well as nursing care and rehabilitation.

20

Rabbit Dentistry SARAH KOLB, RVT, VTS (CLINICAL PRACTICE–EXOTIC COMPANION ANIMALS)

This article provides an overview of rabbit dentistry. Topics discussed include anatomy and physiology of the oral cavity; causes, clinical signs, and treatment of dental disease; diagnostic modalities; and prevention of dental disease.

28

FEATURES Canine Uveitis and the Veterinary Technician SONDRA KURUTS, BS, LVT

Uveitis can be not only a confusing and frustrating diagnosis for owners, but also a sign of underlying, potentially zoonotic disease.

This article provides an overview of essential information for assisting clients and protecting the veterinary team.

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Luxating Patellas: Pathology and Treatment Options MARIA MADDOX, LVT, CCRP, AMCP

Patellar luxation is one of the most common hindlimb orthopedic abnormalities seen in dogs. This article discusses the anatomy, diagnosis, management, and other aspects of patellar luxation with which veterinary technicians should be familiar.

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The Veterinary Technician’s Role in Implementing Fear Free DEBBIE MARTIN, LVT, VTS (BEHAVIOR)

Currently, Fear Freesm certification is only possible for individuals; however, starting in 2018, veterinary hospitals will be able to become Fear Free certified. Learn how you can play a role in decreasing patient stress to improve patient care.

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COLUMNS Editor’s Letter The Credentialing Coalition

LYNNE JOHNSON-HARRIS, RVT......................................... 5

What Moves You? Passion

BRENDA FELLER, LVT, CVT, VTS (ANESTHESIA)................... 7

VET Report Vitals What Does a Rise in Antimicrobial Resistance Mean?

Sidebar Pain Assessment in Small Mammals SARAH KOLB, RVT, VTS (CLINICAL PRACTICE– EXOTIC COMPANION ANIMALS)....................................

Career Challenges Compliance: A Team Effort DEBBIE BOONE, BS, CCS, CVPM.. ...................................

Toxicology Talk Interrupts: Toxicants Resulting in Rapid and Severe Clinical Toxicosis CARRIE LOHMEYER-MAUZY, CVT, BS...............................

VET

8

RACHEL BECK, CVT, PMP. . ................................................. 8

54 36

54

59

62

Final Thoughts Career Success: The Long Run

JULIE SQUIRES, CCFS..................................................... 62

Careers Employment Opportunities. . ...................... 64 Advertiser Index............................................ 64

REHABILITATION TREATMENT OPTIONS FOR PATELLAR LUXATION

BEHAVIOR BECOMING FEAR FREE

DENTISTRY DENTAL DISEASE IN RABBITS

CAREER CHALLENGES IMPROVING CLIENT COMPLIANCE

SURGERY INTERVERTEBRAL DISC HERNIATION

TODAY’SVETERINARYTECHNICIAN | An Official Journal of the NAVC | todaysveterinarytechnician.com | Volume 2, Number 4 | July/August 2017 |

Canine Uveitis RECOGNIZING THE RISKS

ON THE COVER Holly Kitchen, BS, CVT, administers eye drops to a patient. Photo: courtesy of Lyon Duong, University of Florida | UF Photography

NEW! Animal Medical Kits available to sell to your customers for a total clinic approach. Sell

Today’s Veterinary Technician (ISSN 2472-209X print and ISSN 2472-2103 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available. Today’s Veterinary Technician (ISSN 2472-209X; print version) is published bi-monthly (Jan/Feb, Mar/Apr, May/June, Jul/Aug, Sept/Oct, Nov/Dec; 6x per year) by NAVC, 622 East Washington St, Ste 300, Orlando, FL 32801. Periodicals postage paid at Orlando, FL 32801 and additional mailing offices. POSTMASTER: Send all UAA to CFS (See DMM 507.1.5.2); NON-POSTAL AND MILITARY FACILITIES: send address corrections to CDS/ Today’s Veterinary Technician, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

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NADA 141-426, Approved by FDA

BRIEF SUMMARY (For full Prescribing Information, see package insert) Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

Indications: Bravecto kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis) and the treatment and control of tick infestations [Ixodes scapularis (black-legged tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick)] for 12 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater.

Bravecto is also indicated for the treatment and control of Amblyomma americanum (lone star tick) infestations for 8 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater.

Contraindications: There are no known contraindications for the use of the product.

Warnings: Not for human use. Keep this and all drugs out of the reach of children. Keep the product in the original packaging until use, in order to prevent children from getting direct access to the product. Do not eat, drink or smoke while handling the product. Wash hands thoroughly with soap and water immediately after use of the product.

Precautions: Bravecto has not been shown to be effective for 12-weeks duration in puppies less than 6 months of age. Bravecto is not effective against Amblyomma americanum ticks beyond 8 weeks after dosing.

Adverse Reactions: In a well-controlled U.S. field study, which included 294 dogs (224 dogs were administered Bravecto every 12 weeks and 70 dogs were administered an oral active control every 4 weeks and were provided with a tick collar); there were no serious adverse reactions. All potential adverse reactions were recorded in dogs treated with Bravecto over a 182-day period and in dogs treated with the active control over an 84-day period. The most frequently reported adverse reaction in dogs in the Bravecto and active control groups was vomiting.

Percentage of Dogs with Adverse Reactions in the Field Study Adverse Reaction (AR)

Bravecto Group: Percentage of Dogs with the AR During the 182-Day Study (n=224 dogs)

Active Control Group: Percentage of Dogs with the AR During the 84-Day Study (n=70 dogs)

Vomiting

7.1

14.3

Decreased Appetite

6.7

0.0

Diarrhea

4.9

2.9

Lethargy

5.4

7.1

Polydipsia

1.8

4.3

Flatulence

1.3

0.0

In a well-controlled laboratory dose confirmation study, one dog developed edema and hyperemia of the upper lips within one hour of receiving Bravecto. The edema improved progressively through the day and had resolved without medical intervention by the next morning.

For technical assistance or to report a suspected adverse drug reaction, contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www.bravecto.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/ SafetyHealth.

How Supplied: Bravecto is available in five strengths (112.5, 250, 500, 1000, and 1400 mg fluralaner per chew). Each chew is packaged individually into aluminum foil blister packs sealed with a peelable paper backed foil lid stock. Product may be packaged in 1, 2, or 4 chews per package.

Distributed by: Intervet Inc (d/b/a Merck Animal Health) Madison, NJ 07940 Made in Austria Copyright Š 2014 Intervet Inc, a subsidiary of Merck & Company Inc. All rights reserved 154545R1 Reference: Bravecto [prescribing information] Madison, NJ: Merck Animal Health; 2014 Available by veterinary prescription only.

10444295 Bravecto_Brief_Summary_DR1.indd 1

12/17/15 11:21 AM

todaysveterinarytechnician.com

EDITOR’S LETTER

The Credentialing Coalition Lynne Johnson-Harris, RVT | Editor in Chief

I have to say it: I’m thrilled that the Veterinary Nurse Initiative Coalition is moving forward. It is the best thing for our profession.

The goals of the Coalition are: ÆÆ To standardize the credential for the veterinary technician profession in terms of credentialing requirements, title, and scope of practice throughout the United States ÆÆ To have the standardized title be used in all 50 states ÆÆ To set a standard in all 50 states for maintenance of credentials ÆÆ To unify the profession and grow professional recognition ÆÆ To increase veterinary consumer understanding of what credentialed veterinary technicians/nurses do on a daily basis in regard to patient care So why am I so thrilled? I believe we are nurses dealing with furry, feathered, or scaled nonspeaking creatures. We are anesthesia nurses, lab technicians, radiology technicians, ER nurses, and primary care nurses. Need I say more? We can do it all.

Yet our profession is fragmented. We have credentialed veterinary technicians; veterinary technicians who have been formally trained but are not required to become credentialed per their state practice act; veterinary technicians trained by their employer who are veterinary assistants (unless they are grandfathered); certified veterinary assistants; and veterinary assistants trained in practice. That’s way too many categories. Is there another profession that splits itself so many ways? I can’t think of one.

According to Heather Prendergast, BS, RVT, CVPM, SPHR, and a leading member of the Coalition, we need consolidation in our field to remove the confusion. The varied titles and requirements create confusion not only in the profession, but especially for pet owners.

Ask yourself, would you want to be treated for an

EDITOR’S LETTER

illness by someone whose license you’re not sure of?

Clients know what nurses do for them. It would be great for our profession to gain the same respect from clients by understanding we fill the same shoes.

NAVTA wants to bring us all together under one title: registered veterinary nurse.

ON THE AGENDA One of the first items on the agenda is getting the support of veterinarians. We are not competing for their role. We are seeking their recognition of the skills we have earned through training and their trust in delegating responsibility to us. Gaining their backing is critical. Then, once we have increased awareness of our abilities among veterinarians, we head to the states and drive change in our practice acts. Finally, we extend our communications with pet owners to increase their awareness of everything we can do for their beloved family members.

CHEERS TO NAVTA AND THE AVMA The AVMA has been supporting the veterinary technician profession for years and will be working with NAVTA to move the goals of the Coalition forward. Having the AVMA supporting this endeavor is a huge achievement. In a recent press release, Kara Burns, MS, Med, LVT, VTS (Nutrition), and PresidentElect of NAVTA, stated that through standardization and public awareness of the registered veterinary nurse credential, our profession will become better recognized, more able to easily transfer to different states or roles, and, ultimately, more involved in elevating the standard of care we provide.

Now is the time for each of us to get involved and speak up. Contact NAVTA and your state association.

You can let NAVTA know what you think about the credentialing efforts on NAVTA.net. Change won’t happen overnight, so let’s keep the initiative moving forward. I for one want my voice heard!

To find out what NAVTA has already learned, visit the Veterinary Nurse Credential Initiative page on NAVTA.net. 

Do you have a story you’d like to share? Write me at ljohnson@navc.com.

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todaysveterinarytechnician.com WHAT MOVES YOU

WHAT MOVES YOU?

Passion When I was asked to write this column, I started to reflect on my passions in life— what they were when I was a child, and what they are today. I have been lucky enough to transform some of my early passions into my career. As a child, I loved being outside, playing with animals. You could often find me out playing with our pets, the neighbors’ pets, stray pets… I was the child who rescued stray cats and stood up for abused animals. I distinctly remember, as a girl of about 8, chasing some neighbor boys and pelting them with Brenda Feller, LVT, rocks because they were throwing rocks at CVT, VTS (Anesthesia) a stray cat. (Over the years, I have learned Animal Specialty better coping mechanisms when confronted Hospital of Florida with animal abuse, such as volunteering at a humane society.)

Naples, Florida I also had a passion for learning. I still do.

Being able to turn my passion for animals into a profession is a blessing, and it was other people’s passion that allowed it to happen. People like Dr. Harold Knirk, who saw the need for formal training of veterinary technicians and spearheaded the program I attended at Michigan State University, and Dr. John Thurmon, who hired me into the anesthesia section of the University of Illinois and took me under his wing. All the veterinarians who had faith in me and pushed me to do more than I thought I could, and my husband, who always told me I could do anything I set my mind to. When others have faith in you, it truly gives you wings. I am grateful to all those in my profession who have given me that strength and allowed me to reach heights I never expected.

The road hasn’t always been easy, or even straight. Attending Michigan State was not an easy decision. It was a 6.5-hour drive from my home, in a state where I didn’t know a soul. I had to take a leap of faith and step out of my comfort zone. After graduating, I worked at a private practice. My goal was to work at a university in emergency and critical care, but a job in the anesthesia section came up first, and the human resource representative told me I should take it. Little did I know where it would lead! I thoroughly enjoyed my time there, only leaving because I married a resident and we moved.

I took several years off to raise our children (another passion of mine), but I kept up with my love of animals by volunteering at a local humane society and spay/neuter clinic and reading my husband’s veterinary journals. When I went back to work, I jumped in with both

Veterinary technicians are the heart of veterinary medicine. We are passionate and dedicated, and we each have a story to tell. Today’s Veterinary Technician wants to hear yours!

What drives you?

What inspires you?

What moves you?

Send us your story at TVTech_submissions@NAVC.com.

Submissions should be approximately 500 words or less and may be posted on our website or edited for publication in the journal.

Tell us your story!

“ If you follow your passions, you will never be disappointed.”

—Brenda Feller

continued on page 11

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What Does a Rise in Antimicrobial Resistance Mean?

VET REPORT VITALS

VET REPORT VITALS MEET THE AU TH O R

What Does a Rise in Antimicrobial Resistance Mean?

Rachel Beck, CVT, PMP Banfield Pet Hospital Portland, Oregon

IMPLICATIONS OF ANTIMICROBIAL RESISTANCE FOR COMPANION ANIMAL PRACTICE Antimicrobial resistance (AMR) arises when bacteria develop the ability to grow in the presence of antimicrobial drugs. This phenomenon is a natural evolutionary process of bacteria but develops more rapidly through misuse and overuse of antimicrobials.1 Resistance minimizes the medication options to treat bacterial infections and can challenge veterinarians’ ability to provide effective therapy.

Antimicrobial-resistant bacteria pose disease management concerns not only because resistant organisms can be directly transmitted between hosts, but also because resistance may be transmitted between bacterial species. Evidence indicates that antimicrobial-resistant bacteria are transmitted bidirectionally between humans and household animals.

Rachel Beck is a certified veterinary technician and credentialed project manager on the Veterinary Medical Programs team at Banfield Pet Hospital. She currently leads a team of project managers who specialize in implementation. Having been in the veterinary field for over 15 years, she has served roles both in hospitals and at Banfield’s central office. She is passionate about engaging the whole veterinary team in proactive health and wellness as well as about career pathing for paraprofessionals in the industry.

She resides in Portland, Oregon, with her significant other and 2 cats.

Welcome to VET Report Vitals, a column focused on the results of the groundbreaking Banfield Veterinary Emerging Topics (VET) Report™ “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.” This report, a collaboration between the NAVC and Banfield Pet Hospital, focuses on a critical topic: antimicrobial resistance (AMR). It aims to promote prudent antimicrobial use among companion animal practitioners by contributing a baseline of antimicrobial usage data to the discussion on how to achieve better concordance with published guidelines.

This article examines the issue of AMR within the larger “One Health” context by exploring the implications of AMR for veterinary practitioners, clients, and patients. An upcoming article will discuss effective strategies for improving guideline concordance in daily practice.

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todaysveterinarytechnician.com VET REPORT VITALS

shutterstock.com/Pressmaster

Antimicrobial resistance (AMR) arises when bacteria develop the ability to grow in the presence of antimicrobial drugs.

This has implications for the health of companion animal patients, their owners, and their caretakers.

Infection with resistant organisms can lead to longer and more severe infections, increased mortality, and higher costs for treatment.1,2 The growing threat of AMR has contributed to an increased scrutiny of antibiotic use practices in both human and veterinary medicine (FIGURE 1).

Given the importance of antimicrobial drugs in combatting infectious disease, the veterinary profession will undoubtedly continue to use antimicrobials to promote animal health. However, given the implications for companion animal veterinary practice and public health, antimicrobial use will ideally become more judicious and specific to minimize AMR. Although the concept of judicious use of antibiotics

THE IMPLICATIONS

has been clearly defined3 and recommendations for antimicrobial use in certain companion animal disease situations have been developed,4,5 there remain opportunities to promote better awareness of and alignment with these guidelines.6 THE TEAM APPROACH As a veterinary technician, you may be wondering how you can promote prudent use of antimicrobials in your practice. From the receptionist to the veterinary assistant, the entire team can play an important role in antimicrobial stewardship.

Veterinary Technicians Veterinary technicians have a unique role on the team that enables them to recognize risk factors for infection

WHAT DOES A RISE IN AMR MEAN?

Clients

Veterinarians

Less effective treatments for sick pets

Decreasing efficacy of available drugs

Increased veterinary bills

Threatens freedom to practice as we choose

Risk of AMR transmission from their pets

Zoonotic spread of AMR

FIGURE 1. The implications of antimicrobial resistance.

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What Does a Rise in Antimicrobial Resistance Mean?

VET REPORT VITALS

(BOX 1), support veterinarians in antimicrobial stewardship, and act as primary client educators.

Although the veterinarian is responsible for the diagnosis and treatment plan, veterinary technicians assist with diagnosis and care and can help prevent nosocomial infections in the clinic, thus reducing the potential need for antimicrobials. Specific examples of supporting antimicrobial stewardship include7: ÆÆ Performing diagnostics to aid in establishing a definitive diagnosis ÆÆ Knowing proper protocols for culture and susceptibility testing and Gram stains ÆÆ Providing supportive or symptomatic care ÆÆ Protecting sterile field during clean surgical procedures Client education is key to both preventing the need for antimicrobials and reinforcing the treatment plan (BOX 2), which could include symptomatic care for patients not needing antimicrobials or proper antimicrobial administration, when appropriate.

Receptionists The receptionist is the first and last team member clients usually have contact with in the clinic. This sets receptionists apart as the team members who can begin setting expectations for clients (BOX 2) and who can reinforce the treatment plan and home care instructions at the end of the visit. For this reason, receptionists should be educated on the importance of AMR and be able to address basic questions or concerns that clients may have. With receptionist support, the client can better receive and understand the concept of judicious use of antimicrobials.

Veterinary Assistants Veterinary assistants’ responsibilities commonly include providing a clean, safe environment for patients. This includes prevention of nosocomial infections through the following tasks:

BOX 1 Risk Factors for Infection7

ÆÆ Proper cleaning of areas within the clinic, such as ensuring treatment and surgery areas are sanitized ÆÆ Ensuring good hygiene of pets under the clinic’s care, such as keeping kennels and bedding clean Veterinary assistants commonly keep the surgery suite clean and can monitor sterile technique, minimizing the risks for infection during surgery. They also have the ability to reinforce client education from the veterinarian, veterinary technician, and receptionist so that a consistent message is given throughout the visit.

CONCLUSION Use of antimicrobials has serious implications for both veterinary and human healthcare. By taking a team approach, each team member can contribute to antimicrobial stewardship. For more information, see the companion piece on the implications of AMR for companion animal practitioners in the July/ August issue of Today’s Veterinary Practice. 

BOX 2 Client Education Topics Relating to Antimicrobial Use Preventive strategies7  Husbandry and hygiene, especially in multipet households  Routine physical examinations and screening diagnostics  Vaccinations  Parasite control  Dental care  Nutrition Treatment plan  Supportive or symptomatic care instructions  Proper dosing, handling, administration, side effects, and discard instructions for antimicrobials  Follow-up and retest instructions

 Failure to address preventive strategies  Use of IV and urinary catheters

Client expectations

 Wounds

 A physical examination is needed before determination of whether antimicrobials are appropriate

 Dilute urine  Feline leukemia virus infection, feline immunodeficiency virus infection, or other diseases  Endocrine disease  Use of immunosuppressive drugs

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 Diagnostics are typically required before dispensation of antimicrobials  Antimicrobials should be administered as prescribed and finished even if the clinical signs resolve

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todaysveterinarytechnician.com VET REPORT VITALS

References 1. World Health Organization. Global action plan on antimicrobial resistance. 2015. www.wpro.who.int/entity/drug_resistance/ resources/global_action_plan_eng.pdf Accessed September 2016.

2. Weese JS, Giguere S, Guardabassi L, et al. ACVIM consensus statement on therapeutic antimicrobial use in animals and antimicrobial resistance. J Vet Intern Med 2015;29(2):487-498.

3. American Veterinary Medical Association. Judicious therapeutic use of antimicrobials. avma.org/KB/Policies/Pages/JudiciousTherapeutic-Use-of-Antimicrobials.aspx. Accessed October 2016.

4. Weese JS, Blondeau JM, Boothe D, et al. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the International Society for Companion Animal Infectious Diseases. Vet Med Int 2011;2011:263768.

5. Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases). Vet Dermatol 2014;25(3):163-175.

6. American Veterinary Medical Association Task Force for Antimicrobial Stewardship in Companion Animal Practice.

Understanding companion animal practitioners’ attitudes toward antimicrobial stewardship. JAVMA 2015;247(8):883-884.

7. American Association of Feline Practitioners/American Animal Hospital Association. Basic guidelines of judicious therapeutic use of antimicrobials. January 2014. catvets.com/public/PDFs/ PracticeGuidelines/Guidelines/2014AntimicrobialsGuidelines%20 AAHA_AAFP.pdf. Accessed April 2017.

Banfield has always been dedicated to using its extensive data to provide insights to the profession on topics that can improve veterinary care for pets. The first annual Banfield Veterinary Emerging Topics (VET) Report, supported by the collaborative educational efforts of the NAVC, focuses on a critical topic: antimicrobial resistance.

It is titled “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.”

“We are proud to team up with the NAVC on the 2017 VET Report to raise awareness about the critical topic of antimicrobial resistance in companion animal practice and how veterinarians can address it in their own practices,” said Dr. Karen Faunt, Vice President of Medical Quality Advancement at Banfield Pet Hospital.

The full report is available at Banfield.com/ VETReport or VetFolio.com/VETReport.

WHAT MOVES YOU

Passion, continued from page 7

feet in the surgery department of a specialty referral clinic doing—you guessed it—anesthesia.

A lot had changed, but my education served me well. (I was intimidated by the radiology automatic processor because the last time I had worked in a clinic, we hand dipped our radiographs.) I decided to conquer one new task a week.

Eventually, I went for my VTS in anesthesia. This required a lot of hard work, time, and devotion to study, but the never-ending learning curve is part of this profession. And once I had my VTS, my husband convinced me it was time to share my knowledge with others. Despite my doubts, I landed a speaking engagement at Western Veterinary Conference! This opened up an entirely new passion.

While I admit I don’t care for the preparation, I love teaching others how to optimize veterinary anesthesia. I love knowing that patients will be better served when I share my knowledge with other technicians who have the same passions I have.

Why am I passionate about veterinary medicine?

I have always liked the fast pace and the fact that nothing stays the same. When I was at the University of Illinois, we were doing cutting-edge medicine, but would I use those protocols today? No way!

We now have superior analgesic options, and we are always finding new ways to use drugs. I am living proof you can teach an old dog new tricks.

My animals are still my passion. My husband and I usually have at least one rescue pet. (You know, that one from the clinic that no one else wants because it needs a lot of extra care.) We also now have two granddaughters. My hope is that they fearlessly follow their passions wherever that may lead them.

Who knew when I started out all those years ago that I would do anything but work in a general practice?

Then, there were few veterinary technicians, but my oh my, how we have expanded our job opportunities, our continuing education choices, and our professional outlook. Being a veterinary technician is no longer a job, it is a career! I am so proud of my fellow technicians and how far we have come. As I contemplate retirement, I feel confident that the generations following me will continue to expand and improve this profession.

My takeaway message? If you follow your passions, you will never be disappointed. Never be afraid of learning and expanding your horizons.

Be open to new ideas. If I had let fear determine my choices, I would never have pursued becoming a veterinary technician, worked at some amazing places, or found my husband and raised our children. We don’t all have the same passions, but if you follow yours, they will serve you well.

And pass along your passion! 

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Updated from Veterinary Technician September 2009 (Vol 30, No 9) and peer reviewed by Today’s Veterinary Technician. Used with permission from VetFolio, LLC. Veterinary Technician articles published from January 2005 through August 2013 can be accessed without subscription at vetfolio.com/veterinary-technician-archives.

PEER REVIEWED

M E E T T H E AU T H O R

Canine Uveitis and the Veterinary Technician

Sondra Kuruts, BS, LVT Veterinary Eye Center Austin, Texas

Sondra graduated with a bachelor’s degree in veterinary technology from Mercy College in Dobbs Ferry, New York, in 2006. She passed her licensing exam in Texas in January 2007. Since then she has worked at Veterinary Eye Center, PLLC, in Austin.

Canine uveitis can have a big impact on the veterinary nursing team, and yet few technicians know the dangers that can be associated with it. Technicians should think twice when they see a dog with cloudy eyes and take the proper safety precautions. Uveitis can also be a confusing and frustrating diagnosis for owners to receive, so it is essential to have an informed veterinary team to assist clients.

ANATOMY OF THE EYE The eye is divided into 3 chambers, all of which can be affected by uveitis (FIGURE 1). The anterior chamber is the space between the cornea and the iris, which is the anterior-most portion of the eye. The posterior chamber is the space between the iris and the lens. The posterior segment consists of the space between the lens and the retina.

Three layers, or tunics, compose the eye. The sclera is the white part of the eye that helps the eye hold its shape. The choroid lies between the sclera and the retina. The retina lines the back of the innermost portion of the eye and collects light in its rods and cones for transport to the brain, creating vision.

The uvea is the vascular component of the eyeball and consists of the iris, ciliary body, and choroid. The uvea and its components are responsible for producing aqueous humor and maintaining the bloodeye barrier. Aqueous humor is the fluid in the anterior chamber that helps the eye keep its shape; it is constantly being made by the ciliary body and drained through the drainage angle. The uvea also includes the muscles that regulate constriction and dilation of the pupil.

She lives with her husband, a crazy 2-year-old, 2 dogs, 2 cats and a sulphur-crested cockatoo in Round Rock, Texas. She hopes to pursue her specialty in veterinary ophthalmology in 2018.

FIGURE 2. Blue-eyed 7-year-old bassett hound mix with uveitis causing the iris to appear yellow.

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WHAT IS UVEITIS? Uveitis is defined as inflammation of the uveal tract of the eye. Anterior uveitis is inflammation of the iris and ciliary body, and posterior uveitis is inflammation of the choroid. Panuveitis is inflammation of both the anterior and posterior areas of the eye.

A breakdown in the barrier between the eye and the blood supply allows white blood cells and other inflammatory proteins to leak from the vasculature into the eye, causing inflammation of the uveal tract. This will often cause the eye to have a hazy appearance, and normally blue irises may even appear yellow due to inflammation of the iris (FIGURE 2).1 CLINICAL SIGNS The diagnosis of uveitis is made during an eye examination. A basic eye examination consists of checking the pupillary light reflex (the pupil should constrict with bright light) and measuring intraocular pressure, when possible. Increased outflow of fluid from the eye causes an initial drop in eye pressure (ocular hypotension), and a measurement of <5 mm Hg is supportive of a diagnosis of uveitis.2 The presence of aqueous flare is pathognomonic for uveitis. Aqueous flare is seen when a small, direct beam of light creates a “headlights in fog”

FIGURE 1. Anatomy of the canine eye.

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TECHPOINT 

Uveitis is a welldocumented sequela of leptospirosis in humans, dogs, and horses.

Leptospirosis is now one of the most common zoonoses in the world.

effect in the anterior chamber, known as the Tyndall effect.1 In one study, approximately 86% of dogs with uveitis presented with aqueous flare.3 In patients with uveitis, the pupils often become miotic (constricted) due to ciliary spasm. Ciliary spasm can be very uncomfortable and may lead to blepharospasm (squinting) and epiphora (increased tearing).

Episcleral erythema—redness of the sclera— is another common condition seen with uveitis.

Episcleral erythema can be differentiated from

todaysveterinarytechnician.com PEER REVIEWED

conjunctivitis by topical application of epinephrine or phenylephrine; this causes constriction of the superficial blood vessels of the conjunctiva but not the deeper vasculature of the episclera.2 Uveitis may also cause hyphema (red blood cells in the anterior chamber) and hypopyon (white blood cells, or pus, in the anterior chamber), as well as corneal edema.

PATHOLOGY Uveitis can be unilateral (one eye) or bilateral (both eyes). Both unilateral and bilateral uveitis can have a systemic cause. Uveitis can also be either acute or chronic. Treatment of uveitis and the possible underlying cause is essential for the preservation of comfort and vision.4 Ciliary flush, which is the growth of corneal blood vessels, may be stimulated by chronic uveitis.

Chronic uveitis may cause adhesions of the iris to the lens, known as posterior synechiae, or adhesions of the iris to the cornea, called anterior synechiae.

Both posterior and anterior synechiae can prevent drainage of aqueous humor from the eye. This causes an increase in intraocular pressure, known as secondary glaucoma. Glaucoma can be a chronic, very painful, and blinding condition that often requires surgical intervention for patient comfort.

Uveitis of the posterior segment can cause an accumulation of inflammatory fluid underneath the retina. It is possible for this fluid to push the retina off of the choroid. Detachment of the retina from the choroid causes blindness.

ETIOLOGY The cause of the disruption of the blood-eye barrier during uveitis can be external (eg, trauma, corneal ulceration or perforation; FIGURE 3) or internal.2 There are many internal causes of uveitis (BOX 1), therefore, an extensive medical history

BOX 1 Potential Causes of Canine Uveitis INFECTIOUS Bacterial  Borrelia burgdorferi (Lyme disease)  Brucella canis  Ehrlichia canis  Leptospira species  Rickettsia rickettsii (Rocky Mountain spotted fever) Fungal  Aspergillus species  Blastomyces species  Coccidioides species  Cryptococcus species  Histoplasma species Viral  Adenovirus (canine infectious hepatitis)  Distemper virus  Herpesvirus  Rabies virus Parasitic  Dirofilaria immitis  Leishmania species  Toxoplasma species Other  Prototheca species  Septicemia NONINFECTIOUS  Coagulopathies  Diabetes mellitus  Hyperlipidemia  Hypertension  Immune-mediated or idiopathic uveitis  Lens-induced uveitis (eg, cataracts)  Pigmentary uveitis in golden retrievers  Primary neoplastic disease (eg, ocular melanoma)  Secondary neoplastic disease  Trauma  Ulcerative keratitis  Uveodermatologic syndrome

FIGURE 3. Seven-year-old chihuahua with a history of traumatic uveitis leading to phthisis bulbi in the left eye.

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and diagnostic evaluation is necessary to investigate possible systemic causes. Evaluation should start with a complete physical examination, as well as a complete blood count (CBC) and biochemistry profile.1 Infectious disease testing should be performed based on individual history and geographic location.

Cataracts (all stages) can cause an immunemediated form of uveitis. The immune system reacts to lens proteins from the cataract leaking out of the lens capsule. Treatment of uveitis in dogs with cataracts is necessary not only before cataract surgery, to preserve the potential for vision, but also for long-term comfort.1 In one study of causes of uveitis in 102 dogs, 25% were diagnosed with metastatic neoplastic disease.3 For this reason, chest radiographs and abdominal ultrasound can be valuable tools when identifying possible causes of uveitis.

Unfortunately, in some cases of uveitis an underlying condition cannot be identified.

These cases are presumed to be idiopathic or immune-mediated after a thorough process of elimination. In the above study, 58% of dogs examined with uveitis were diagnosed with idiopathic or immune-mediated uveitis.3 The remaining 17% of dogs in the study were diagnosed with uveitis caused by infectious disease.3 Infectious causes of uveitis include bacterial, fungal, viral, and parasitic agents.

ZOONOTIC POTENTIAL Many infectious diseases can cause uveitis, and veterinary personnel should be aware of the zoonotic potential of animals presenting with this eye condition.

Leptospirosis Most significantly, uveitis is a well-documented sequela of leptospirosis in humans, dogs, and horses. Leptospirosis is now one of the most common zoonoses in the world.5 It is possible for dogs to develop uveitis from leptospirosis before developing other clinical signs.

Vaccines for leptospirosis are available; however, multiple serovars of leptospirosis can cause uveitis, and not all are currently included in vaccines. Dogs vaccinated for leptospirosis should still be tested for leptospirosis as part of their workup if they present with uveitis. It is important to note that it is possible for dogs to become infected with leptospirosis and shed the virus without ever having a titer above 1:100.6 Leptospirosis bacteria are transmitted through contact with infected urine. It is not uncommon for affected dogs to carry urine on their fur; therefore, personnel who come in contact with a dog that is possibly infected with leptospirosis—or other

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Veterinary technicians must be aware of the potential effects of uncontrolled uveitis and able to accurately and confidently relay that information to clients. zoonotic disease—should wear gloves and practice frequent handwashing. Recognition of uveitis and its potential causes is important for personal protection as well as for providing total patient care.

Brucellosis Brucella canis is another cause of uveitis that can be transmitted to veterinary personnel. It is especially dangerous for women who are pregnant or may become pregnant, as it can cause spontaneous abortion.7 No vaccine for brucellosis currently exists, so all intact, breeding dogs with uveitis should be tested for this bacterial infection.

TREATMENT The immediate goals of uveitis treatment involve stabilizing the blood-eye barrier, providing comfort, maintaining vision, and minimizing inflammation.

Treatment depends on the underlying cause of uveitis; for example, systemic antibiotic or antifungal medications may be prescribed.

It is possible to resolve uveitis and eventually discontinue medication after the underlying cause is addressed. Unfortunately, many cases do not have an underlying cause that can be diagnosed or cured, such as with idiopathic or immunemediated uveitis.3 These dogs often require longterm topical and/or oral medical treatment that is tapered down to the lowest effective dose.

Treatment options consist of topical nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, as well as mydriatic agents. The most common topical NSAIDs include flurbiprofen sodium, diclofenac sodium, and ketorolac tromethamine.

The topical corticosteroids dexamethasone and prednisolone acetate are used because they can penetrate the cornea into the anterior chamber of the eye. Hydrocortisone does not efficiently penetrate the cornea; therefore, it does not achieve a therapeutic level in the aqueous humor.1

NOT ALL FLEA AND TICK CHEWS ARE CREATED EQUAL

Flea and tick protection that goes on and on and on...all month long

Introducing Simparica Monthly chewables for dogs that offer persistent protection from fleas and ticks.

Simparica acts fast—it starts killing fleas within 3 hours and ticks within 8 hours1 —and keeps going strong for 35 days2 without losing effectiveness at the end of the month.

IMPORTANT SAFETY INFORMATION: Simparica is for use only in dogs, 6 months of age and older.

Simparica may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures. Simparica has not been evaluated in dogs that are pregnant, breeding or lactating. Simparica has been safely used in dogs treated with commonly prescribed vaccines, parasiticides and other medications. The most frequently reported adverse reactions were vomiting and diarrhea. See full Prescribing Information on the back of this page and at www.zoetisUS.com/SimparicaPI.

Fetch more information about Simparica from Zoetis Customer Service at 1-888-ZOETIS-1 or 1-888-963-8471.

References: 1. Six RH, Geurden T, Carter L, et al. Evaluation of the speed of kill of sarolaner (Simparica™) against induced infestations of three species of ticks (Amblyomma maculatum, Ixodes scapularis, Ixodes ricinus) on dogs. Vet Parasitol. 2016;222:37-42. 2. Six RH, Everett WR, Young DR, et al. Efficacy of a novel oral formulation of sarolaner (Simparica™) against five common tick species infesting dogs in the United States. Vet Parasitol. 2016;222:28-32.

All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. © 2016 Zoetis Services LLC. All rights reserved. October 2016. SMP-00048

TM

(sarolaner) Chewables

FOR ORAL USE IN DOGS ONLY CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

Description: SIMPARICA is a flavored, chewable tablet for administration to dogs over 6 months of age according to their weight. Each tablet is formulated to provide a minimum sarolaner dosage of 0.91 mg/lb (2 mg/kg) body weight.

Sarolaner is a member of the isoxazoline class of parasiticides and the chemical name is 1-(5’-((5S)-5-(3,5-Dichloro-4-fluorophenyl)-5-(trifluoromethyl)-4,5-dihydroisoxazol-3-yl)-3’H-spiro(azetidine-3,1’-(2)benzofuran)-1-yl)-2-(methylsulfonyl)ethanone. SIMPARICA contains the S-enantiomer of sarolaner.

The chemical structure of the S-enantiomer of sarolaner is: F F

F O

N

O

CI

F

CI N

O O

S O

Indications: SIMPARICA kills adult fleas, and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of tick infestations [Amblyomma americanum (lone star tick), Amblyomma maculatum (Gulf Coast tick), Dermacentor variabilis (American dog tick), Ixodes scapularis (black-legged tick), and Rhipicephalus sanguineus (brown dog tick)] for one month in dogs 6 months of age or older and weighing 2.8 pounds or greater.

Dosage and Administration: SIMPARICA is given orally once a month at the recommended minimum dosage of 0.91 mg/lb (2 mg/kg).

Dosage Schedule: Body Weight SAROLANER per Tablet (mg) Number of Tablets Administered 2.8 to 5.5 lbs 5 One 5.6 to 11.0 lbs 10 One 11.1 to 22.0 lbs 20 One 22.1 to 44.0 lbs 40 One 44.1 to 88.0 lbs 80 One 88.1 to 132.0 lbs 120 One >132.1 lbs Administer the appropriate combination of tablets SIMPARICA can be offered by hand, in the food, or administered like other tablet medications.

Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If a dose is missed, administer SIMPARICA and resume a monthly dosing schedule.

SIMPARICA should be administered at monthly intervals.

Flea Treatment and Prevention: Treatment with SIMPARICA may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with SIMPARICA can continue the entire year without interruption.

To minimize the likelihood of flea re-infestation, it is important to treat all dogs and cats within a household with an approved flea control product.

Tick Treatment and Control: Treatment with SIMPARICA can begin at any time of the year (see Effectiveness).

Contraindications: There are no known contraindications for the use of SIMPARICA. Warnings: Not for use in humans. Keep this and all drugs out of reach of children and pets. For use in dogs only. Do not use SIMPARICA in cats.

SIMPARICA should not be used in dogs less than 6 months of age (see Animal Safety).

Precautions: SIMPARICA may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures (see Animal Safety).

The safe use of SIMPARICA has not been evaluated in breeding, pregnant, or lactating dogs.

Adverse Reactions: SIMPARICA was administered in a well-controlled US field study, which included a total of 479 dogs (315 dogs treated with SIMPARICA and 164 dogs treated with active control once monthly for three treatments).

Over the 90-day study period, all observations of potential adverse reactions were recorded.

Table 1. Dogs with adverse reactions Adverse reaction sarolaner sarolaner active control active control N % (n = 315) N % (n =164) Vomiting 3 0.95% 9 5.50% Diarrhea 2 0.63% 2 1.20% Lethargy 1 0.32% 2 1.20% Inappetence 0 0% 3 1.80%

Additionally, one female dog aged 8.6 years exhibited lethargy, ataxia while posturing to eliminate, elevated third eyelids, and inappetence one day after receiving SIMPARICA concurrently with a heartworm preventative (ivermectin/pyrantel pamoate). The signs resolved one day later. After the day 14 visit, the owner elected to withdraw the dog from the study.

For a copy of the Safety Data Sheet (SDS) or to report adverse reactions call Zoetis Inc. at 1-888-963-8471. Additional information can be found at www.SIMPARICA.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or http://www.fda.gov/AnimalVeterinary/SafetyHealth.

Clinical Pharmacology: Sarolaner is rapidly and well absorbed following oral administration of SIMPARICA. In a study of 12 Beagle dogs the mean maximum plasma concentration (Cmax) was 1100 ng/mL and the mean time to maximum concentration (Tmax) occurred at 3 hours following a single oral dose of 2 mg/kg to fasted animals. The mean oral bioavailability was 86% and 107% in fasted and fed dogs, respectively. The mean oral T1/2 values for fasted and fed animals was 10 and 12 days respectively.

Sarolaner is distributed widely; the mean volume of distribution (Vdss) was 2.81 L/kg bodyweight following a 2 mg/kg intravenous dose of sarolaner. Sarolaner is highly bound (≥99.9%) to plasma proteins. The metabolism of sarolaner appears to be minimal in the dog.

The primary route of sarolaner elimination from dogs is biliary excretion with elimination via the feces.

Following repeat administration of SIMPARICA once every 28 days for 10 doses to Beagle dogs at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, steady-state plasma concentrations were reached after the 6th dose. Following treatment at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, sarolaner systemic exposure was dose proportional over the range 1X to 5X. Mode of Action: The active substance of SIMPARICA, sarolaner, is an acaricide and insecticide belonging to the isoxazoline group. Sarolaner inhibits the function of the neurotransmitter gamma aminobutyric acid (GABA) receptor and glutamate receptor, and works at the neuromuscular junction in insects. This results in uncontrolled neuromuscular activity leading to death in insects or acarines.

Effectiveness: In a well-controlled laboratory study, SIMPARICA began to kill fleas 3 hours after initial administration and reduced the number of live fleas by ≥96.2% within 8 hours after flea infestation through Day 35.

In a separate well-controlled laboratory study, SIMPARICA demonstrated 100% effectiveness against adult fleas within 24 hours following treatment and maintained 100% effectiveness against weekly re-infestations for 35 days.

In a study to explore flea egg production and viability, SIMPARICA killed fleas before they could lay eggs for 35 days. In a study to simulate a flea-infested home environment, with flea infestations established prior to the start of treatment and re-infestations on Days 7, 37 and 67, SIMPARICA administered monthly for three months demonstrated >95.6% reduction in adult fleas within 14 days after treatment and reached 100% on Day 60.

In well-controlled laboratory studies, SIMPARICA demonstrated ≥99% effectiveness against an initial infestation of Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, Ixodes scapularis, and Rhipicephalus sanguineus 48 hours post-administration and maintained >96% effectiveness 48 hours post re-infestation for 30 days.

In a well-controlled 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of SIMPARICA against fleas on Day 30, 60 and 90 visits compared to baseline was 99.4%, 99.8%, and 100%, respectively. Dogs with signs of flea allergy dermatitis showed improvement in erythema, papules, scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct result of eliminating fleas.

Animal Safety: In a margin of safety study, SIMPARICA was administered orally to 8-week-old Beagle puppies at doses of 0, 1X, 3X, and 5X the maximum recommended dose (4 mg/kg) at 28-day intervals for 10 doses (8 dogs per group). The control group received placebo tablets. No neurologic signs were observed in the 1X group. In the 3X group, one male dog exhibited tremors and ataxia post-dose on Day 0; one female dog exhibited tremors on Days 1, 2, 3, and 5; and one female dog exhibited tremors on Day 1. In the 5X group, one female dog had a seizure on Day 61 (5 days after third dose); one female dog had tremors post-dose on Day 0 and abnormal head coordination after dosing on Day 140; and one female dog exhibited seizures associated with the second and fourth doses and tremors associated with the second and third doses. All dogs recovered without treatment. Except for the observation of abnormal head coordination in one dog in the 5X group two hours after dosing on Day 140 (dose 6). There were no treatment-related neurological signs observed once the dogs reached the age of 6 months.

In a separate exploratory pharmacokinetic study, one female dog dosed at 12 mg/kg (3X the maximum recommended dose) exhibited lethargy, anorexia, and multiple neurological signs including ataxia, tremors, disorientation, hypersalivation, diminished proprioception, and absent menace, approximately 2 days after a third monthly dose. The dog was not treated, and was ultimately euthanized. The first two doses resulted in plasma concentrations that were consistent with those of the other dogs in the treatment group. Starting at 7 hours after the third dose, there was a rapid 2.5 fold increase in plasma concentrations within 41 hours, resulting in a Cmax more than 7-fold higher than the mean Cmax at the maximum recommended use dose.

No cause for the sudden increase in sarolaner plasma concentrations was identified.

Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F).

How Supplied: SIMPARICA (sarolaner) Chewables are available in six flavored tablet sizes: 5, 10, 20, 40, 80, and 120 mg. Each tablet size is available in color-coded packages of one, three, or six tablets.

NADA #141-452, Approved by FDA Distributed by: Zoetis Inc. Kalamazoo, MI 49007 Made in Switzerland

Revised: July 2016

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Systemic NSAIDs or corticosteroids may be used if topical medications cannot successfully control the uveitis. Systemic corticosteroids should be used cautiously because they may exacerbate infectious causes of uveitis.

In some immune-mediated cases, if systemic and topical NSAIDs and corticosteroids fail, an immunosuppressive drug such as azathioprine or mycophenolate may be used to control uveitis. However, the CBC should be carefully monitored to check for a decrease in white blood cells, red blood cells, and platelets.2 Topical atropine ointment or solution is the most commonly used mydriatic (causes pupil dilation) and cycloplegic (causes paralysis of the ciliary muscles of the eye). Atropine relaxes the pupillary muscles, which relieves ciliary spasm, provides comfort, stabilizes the blood-eye barrier, and reduces infiltration of inflammatory cells into the eye. Mydriatic medications should be used with caution, as they can exacerbate glaucoma.

THE ROLE OF THE VETERINARY TECHNICIAN Uncontrolled uveitis can be devastating to the eyes and wellbeing of the canine patient. Often, veterinary technicians are responsible for assistance in diagnosis (BOX 2) and care of dogs with uveitis.

Veterinary technicians are often the educators and comforters of clients whose dogs have been diagnosed with this condition. Client education about uveitis can be difficult because of the many causes and often extensive treatment. It is necessary for veterinary technicians to be aware of the potential

effects of uncontrolled uveitis and able to accurately and confidently relay that information to clients.

CONCLUSION Canine uveitis is often a subtle and frustrating disease. Diagnosis of uveitis and consideration of potential causes are necessary to control uveitis. Treatment of the underlying cause may eliminate uveitis; however, medication is often required for long periods of time. Uncontrolled uveitis can lead to discomfort and blindness.

Clinic staff should be aware of the possible zoonotic risks and take the proper precautions to protect themselves. Client compliance is essential for treatment of uveitis, and it is often up to the veterinary technician to educate clients on the importance of medicating and controlling uveitis.

When uveitis is controlled, it is possible to provide these dogs with comfort as well as preserve vision.  References 1. Gelatt KN, Gilger BC, Kern TJ. Veterinary Ophthalmology. 5th ed.

Ames: Wiley-Blackwell; 2013:1-2264.

2. Gelatt KN. The canine anterior uvea. In: Gelatt KN, ed. Essentials of Veterinary Ophthalmology. Baltimore: Lippincott Williams & Wilkins; 2000:197-225.

3. Massa KL, Gilger BC, Miller TL, Davidson MG. Causes of uveitis in dogs: 102 cases (1989-2000). Vet Ophthalmol 2002;5(2):93-98.

4. Johnsen DA, Maggs DJ, Kass PH. Evaluation of risk factors for development of secondary glaucoma in dogs: 156 cases (1999–2004). JAVMA 2006;229(8):1270-1274.

5. Sykes JE, Hartmann K, Lunn KF, et al. 2010 ACVIM small animal consensus statement on leptospirosis: diagnosis, epidemiology, treatment, and prevention. J Vet Intern Med 2011;25(1):1-13.

6. Townsend WM, Stiles J, Krohne SG. Leptospirosis and panuveitis in a dog. Vet Ophthalmol 2006;9(3):169-173.

7. Glynn MK, Lynn TV. Brucellosis. JAVMA 2008;233(6):900-908.

BOX 2 Sample Questions for Clients When Their Dog Presents for Uveitis  Any changes in appetite or weight?  Any changes in overall energy levels?  Any coughing, sneezing, or difficulty breathing?  Any recent illnesses?  Does your dog have any access to cat feces, either from a litterbox or outside?  Does your dog have any known medical conditions?  Has your dog been able to swim in or drink from any lakes or streams? shutterstock.com/MirasWonderland

 Has your dog eaten any raw meat?  Has your dog ever travelled outside of your region?  Has your dog experienced any vomiting or diarrhea?  Is your dog current on heartworm preventive medication?  When was your dog last vaccinated?  Which vaccines did your dog receive?

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1 Credit Continuing Education | Peer Reviewed

CONTINUING EDUCATION

PEER REVIEWED

M E E T T H E AU T H O R

Intervertebral Disc Herniation Intervertebral disc herniation (IVDH) is the most common spinal disease in dogs. This painful and debilitating disease occurs in about 2% of canine patients seen at teaching hospitals but is rarely seen in cats, horses, and food animals.1 Hansen first classified intervertebral disc (IVD) disease as type I and type II in 1951. Type I IVDH is an extrusion of the nucleus pulposus, and type II IVDH is a protrusion of the annulus fibrosis. Management of IVDH by a combination of medical and surgical methods is now well established, with high success rates reported (up to 95%).2 Veterinary technicians can play an important role in management of these cases.

PATHOPHYSIOLOGY Intervertebral discs separate the vertebral bodies along the entire length of the spinal column, with the exception of the atlanto-axial joint, and between the bones of the sacrum.3 These discs permit motion of the spine while providing support under movement. The annulus fibrosis is the ligament that makes up the periphery of the disc and attaches to the vertebral end plates. The nucleus pulposus is the highly hydrated central portion of the disc (FIGURE 1). A common aging process known as fibroid metaplasia can result in degenerative changes in the disc. In this process, a decrease in proteoglycans, due to pathologic or age-related changes, results in decreased water content within the nucleus and annulus. These degenerative changes are accelerated in chondrodystrophic dogs, which predisposes them to early IVD degeneration.

Stephanie Gilliam, RVT, BS, CCRP, VTS (Neurology) University of Missouri Veterinary Health Center

Stephanie received her associate of applied science degree in veterinary technology from Jefferson College in Hillsboro, Missouri, in 2005. She began working at the University of Missouri Veterinary Health Center as the neurology/neurosurgery technician in 2007 and received her certification in canine rehabilitation from the University of Tennessee in 2008. She received her bachelor’s degree in veterinary technology from St. Petersburg College in 2011 and her Veterinary Technician Specialist credential in neurology in June 2013.

Stephanie is a deputy member with the proposed Academy of Physical Rehabilitation Veterinary Technicians as well as an adjunct clinical instructor with the Biomedical Sciences Online Program at the University of Missouri. She is pursuing her master’s degree in biomedical sciences with an emphasis in veterinary sciences.

MYELOGRAPHY uses contrast material injected into the subarachnoid space and review of a series of radiographs. After the contrast material outlined the spinal cord in this image, attenuation of the contrast agent identified the site of spinal cord compression.

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Type I As noted above, 2 types of disc degeneration have been described. Hansen type I IVD degeneration occurs commonly in chondrodystrophic breeds, such as the dachshund and beagle. However, it may also be seen in large breeds. This type of degeneration leads to an extrusion of the nucleus pulposus into the vertebral canal. Type I IVD degeneration affects young animals, with clinical signs developing between ages 3 and 6 years. Calcification of the degenerative disc is radiographically apparent in dachshunds by 6 to 18 months of age.1 The degenerative process leads to a weakened annulus that cannot confine the calcified nucleus pulposus. Normal movements of the spinal column are enough to cause an acute disc herniation. This extrusion of nucleus pulposus leads to an acute onset of clinical signs.

Type II Hansen type II IVD degeneration is most common in large nonchondrodystrophic breeds, such as the German shepherd and Labrador retriever. Fibroid metaplasia leads to a slow protrusion of the disc into the spinal canal. Both the annulus and the nucleus can protrude, but the annulus remains intact. Hansen type II degeneration develops more slowly than type I, and clinical signs become apparent between 5 and 12 years of age. Spinal cord compression from Hansen type II IVDH results in a slowly progressive myelopathy. German shepherds and Labrador retrievers may present with Hansen type I or type II IVD degeneration.

Traumatic Traumatic IVDH is an acute, noncompressive nucleus pulposus extrusion. It is less common than

FIGURE 1. Position of the intervertebral disc.

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TECHPOINT 

Intervertebral disc herniation is the most common spinal disease in dogs and occurs in about 2% of canine patients seen at teaching hospitals.

Hansen types I and II but has been documented with magnetic resonance imaging (MRI). This type of IVDH usually results from heavy exercise that exerts excessive force on the disc. The result is expulsion of the nucleus pulposus through the annulus into the spinal canal. It is a low-volume/ high-velocity herniation. The gelatinous nucleus pulposus then disperses along the floor of the canal and does not cause spinal cord compression.1 CLINICAL SIGNS Clinical signs of IVDH can range from spinal hyperesthesia (back pain) only to paraplegia without pain sensation. Spinal hyperesthesia is caused by compression of the nerve roots and meninges.

Animals may have a hunchback appearance (kyphosis) and tense abdominal muscles if they are in pain.

Paresis (weakness) or plegia (paralysis) may affect any limb depending on where the disc herniation is along the spine. When describing the extent of clinical signs, mono refers to one limb; hemi, to limbs on one side (eg, right thoracic and pelvic); para, to pelvic limbs; and tetra, to all 4 limbs.

For example, if the disc herniation is in the cervical spine, the animal may be tetraparetic (weak in all 4 limbs). However, if the disc herniation is in the caudal thoracic spine, the animal may be paraparetic (weak in the pelvic limbs). If the animal has lost all movement to the affected limbs, the correct term is plegia. If an animal is paraplegic, it is important to check the affected limbs for nociception (the ability to feel pain) because lack of nociception does affect prognosis. The disc herniation may be lateralized and compress one side of the spinal cord more than the other, which may produce asymmetric clinical signs.

DIAGNOSIS A presumptive diagnosis may be made on the basis of signalment, history, clinical signs, and neurologic examination findings. However, a definitive diagnosis

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can be based only on further diagnostic testing, such as myelography, computed tomography (CT), or MRI. Radiography Spinal radiography may show evidence of a degenerative disc and may also rule out other diagnostic differentials, such as neoplasia, discospondylitis, or spinal fracture.

To obtain proper positioning for spinal radiography, the patient should be heavily sedated or under general anesthesia. Radiographic changes suggestive of IVDH include narrowing of the IVD space, narrowing of the space between the articular processes, and a small intervertebral foramen. Mineralized discs may sometimes be seen in the vertebral canal (FIGURE 2).1 Myelography Myelography used to be the standard diagnostic modality for spinal cord compression. This technique used contrast material injected into the subarachnoid space and review of a series of radiographs. After the contrast material outlined the spinal cord, attenuation of the contrast agent identified the site of spinal cord compression (FIGURE 3). Injection of contrast material was associated with possible complications, including seizures. With myelography, clinical signs could also be exacerbated because of iatrogenic trauma or hemorrhage caused by spinal injections.1

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and is now considered the standard modality for evaluation of IVDH. CT may be used in conjunction with myelography to better delineate lateralization of the IVDH but may also be used as the sole diagnostic modality. It is noninvasive and fast, with images acquired in minutes. Diagnosis of spinal cord compression by using CT is similar to diagnosis via radiography in that it is based on identifying the anatomic landmarks where attenuation of the spinal cord is visible, but compared with radiography, it offers enhanced soft tissue contrast and visualization (FIGURE 4). CT does have some advantages over MRI in the evaluation of bony lesions.

In cases such as vertebral fractures or luxations, CT may provide more useful information than does MRI. Magnetic Resonance Imaging MRI is the gold standard imaging modality for almost all neurologic disease processes. It provides superior soft tissue contrast, which allows further differentiation of anatomic structures. Like CT, images may be viewed in many different planes (sagittal, transverse, dorsal), which allows close scrutiny of anatomic regions (FIGURE 5). In patients with multiple affected sites, MRI is best for differentiating the inciting cause of the current clinical signs.

Computed Tomography Cross-sectional imaging, such as CT or MRI, is required to determine the active region of spinal cord compression,

FIGURE 2. Radiograph showing mineralized intervertebral discs.

FIGURE 4. CT scan with arrow pointing to herniated disc within the spinal canal causing compression of the spinal cord.

FIGURE 3. Myelogram with arrowheads showing attenuation of contrast column at site of compression.

FIGURE 5. Sagittal MRI image with arrow pointing to herniated disc material within the spinal canal causing compression of the spinal cord.

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MRI is based on the properties of hydrogen atoms, which are numerous in tissues with a high water content. When placed in a magnetic field, the hydrogen atoms line up. A radiofrequency pulse knocks the atoms out of alignment. When that pulse is removed, the atoms bounce back to their previous orientation and release energy in the form of another radiofrequency pulse. This second radiofrequency pulse is captured to form the resultant image.

The typical MRI finding with disc protrusion or extrusion is focal extradural spinal cord compression centered over a disc space.3 MRI has few contraindications other than anesthetic risks (the patient requires general anesthesia to undergo MRI). Metallic implants or foreign bodies, such as gunshot, can cause artifacts in the images or can move during the procedure and harm the patient.

TREATMENT Treatment recommendations for IVDH vary from case to case. There are no straightforward guidelines on which treatment option is best; rather, guidelines are based on whether surgery should be included as part of the treatment. There are pros and cons to surgery for IVDH. Clients should be informed of the benefits and risks of each treatment option before they make a decision.

Conservative Therapy Conservative therapy is indicated for animals that have one episode with mild clinical signs, those whose owners have financial constraints, or those with other medical problems that preclude anesthesia and surgery. Hansen type II IVDH is more commonly treated with conservative therapy. These patients may be treated successfully for long periods with conservative management consisting of pain control and cage confinement; the more important of these is confinement. Strict cage rest is recommended for 4 to 6 weeks. The kennel should be big enough for patients to stand up and turn around in but not big enough for them to walk around in. The patient is let out of the kennel only to go on short-leash walks to urinate and defecate. If improvement is seen, exercise is restricted to a leash for another 3 weeks.

Analgesics and anti-inflammatory drugs should be used only if the client agrees to cooperate with the confinement instructions. Anti-inflammatory drugs, such as corticosteroids or nonsteroidal antiinflammatory drugs (NSAIDs), alleviate pain and thus allow most dogs to be more active. This activity may cause more pressure to be placed on the disc, thereby leading to extrusion of more disc material into the vertebral canal. NSAIDs, gabapentin, or tramadol may be used for pain control. Some clinicians prefer an anti-inflammatory dose of prednisone in a decreasing regimen. However, steroids and NSAIDs should never

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be administered concurrently because doing so may cause severe gastrointestinal complications.3 Physical rehabilitation, weight control, and prevention of jumping may help to reduce the risk for recurrence.1 Surgery The following scenarios would require surgical management: ÆÆ Hansen type I cervical or thoracolumbar IVDH that is associated with minimal neurologic deficits but is refractory to conservative therapy. ÆÆ Hansen type I cervical IVDH with moderate to severe neurologic deficits (nonambulatory tetraparesis or tetraplegia). An acute onset of tetraplegia is a surgical emergency. ÆÆ Hansen type I thoracolumbar IVDH resulting in nonambulatory paraparesis to paraplegia. Dogs presenting with lack of nociception (or deep pain perception) should ideally have immediate decompressive surgery within 24 hours of onset of clinical signs. Prolonged loss of pain perception carries a poor prognosis. ÆÆ Hansen type I cervical or thoracolumbar IVDH causing deteriorating neurologic status, regardless of the severity of neurologic deficits.3 Many decompressive surgeries are used to treat IVDH, including hemilaminectomy, dorsal laminectomy, ventral slot (for cervical IVDH), and pediculectomy.

Hemilaminectomy improves retrieval of herniated disc with minimal spinal cord manipulation (FIGURE 6).

Pediculectomy can be used as an adjunct technique in cases of a bilateral approach.1 If surgery is required for Hansen type II IVDH, a hemilaminectomy, corpectomy, or pediculectomy is usually performed.3 Outcomes Many dogs treated conservatively demonstrate initial improvement. Approximately 50% to 100% of patients recover with medical management, with a 30% to 50% relapse rate.3 The recovery rate in nonambulatory patients treated conservatively is lower; deep

FIGURE 6. Hemilaminectomy.

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pain–negative dogs treated conservatively have a recovery rate of 5% to 10%.3 Among patients with Hansen type I IVDH that have intact pain perception, functional recovery is expected in 80% to 95%.

In patients with Hansen type I IVDH, the average time to ambulation is about 2 weeks. In nonambulatory tetraparetic or tetraplegic dogs with Hansen type I IVDH, it is reportedly about 1 week.

The absence of deep pain perception is associated with a poor prognosis. A recovery rate of about 50% is reported for dogs with absent pain perception.

These dogs may have a better outcome if they undergo surgery within 12 to 24 hours of losing deep pain perception.3 The prognosis after surgical treatment of Hansen type II IVDH is guarded compared with that for Hansen type I IVDH, especially for thoracolumbar lesions.

Neurologic deterioration after surgery is more common with Hansen type II IVDH, but the reason is unknown.3 A condition known as myelomalacia is a concern for dogs without deep pain perception. Myelomalacia is liquefaction of the spinal cord parenchyma. It may be focal or diffuse. Myelomalacia affects 10% of dogs lacking deep pain perception.3 Therefore, if a dog does not have deep pain perception, the surgeon may elect to perform a durotomy during surgery to visualize the spinal cord. Diffuse myelomalacia carries a grave prognosis.

Recovery in dogs with focal myelomalacia is rare.

NURSING CARE AND REHABILITATION Supportive Care Supportive care of nonambulatory animals should include prevention of decubital ulcers, urinary tract infections, and muscle atrophy. To prevent decubital ulcers, the animal should be kept on a well-padded bed and rotated from side to side every 4 to 6 hours (FIGURE 7). The skin over bony prominences

FIGURE 7. Decubital ulcer.

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should be checked daily for reddening. The patient should be kept clean and dry at all times.

Nonambulatory dogs with thoracolumbar IVDH are often unable to voluntarily urinate. If this is the case, the bladder will need to be manually expressed by applying gentle pressure to the caudal abdomen, or the patient will need intermittent or indwelling urinary catheter placement. Animals that cannot voluntarily empty their bladder completely are at risk for urinary tract infections. The urine should be monitored for foul odor and change in color so that treatment may be instituted if a urinary tract infection does develop.

Physical Rehabilitation Physical rehabilitation can help to shorten the recovery time for return to ambulation.1 Before a physical rehabilitation plan is developed for any patient with IVDH, it is important to consider the various stages of healing so that treatments may be better customized.

Postoperative patients will need to be kept strictly rested for 6 to 8 weeks. These patients are allowed out of the kennel for only a few minutes 3 times daily to urinate and defecate and to perform controlled physical rehabilitation exercises. When out of the kennel, they should be kept controlled while on a short leash.

Postoperative pain from inflammation may be relieved by cryotherapy. A cold pack should be applied to the incision for 10 to 15 minutes every 4 hours for the first 48 hours after surgery.4 After the acute inflammatory period of healing is over, heat therapy may be instituted. This can be accomplished by using a commercially available gel pack. The heat pack can be applied to the incision for 10 to 15 minutes every 4 to 6 hours before other exercises are begun. The patient should be closely monitored during these treatments.

Passive range of motion (PROM) is intentional movement of a joint that is performed without muscle contraction. It is used when a patient is unable to move joints on its own or when active movement may be deleterious to the patient. PROM can be performed immediately after surgery and before active weight-bearing and is used to help prevent joint contracture, maintain mobility of soft tissue, reduce pain, enhance blood and lymphatic flow, and improve synovial fluid production. PROM will help maintain joint health; however, it will not improve strength or prevent muscle atrophy. Proper technique for PROM is important. The patient should be relaxed in lateral recumbency and the limb should be supported. The upper limbs are put through a comfortable flexion and extension for 15 to 20 cycles. The limb is then moved through a “bicycle” pattern another 15 to 20 times. This is repeated on each limb and is performed 3 to 4 times a day until the patient is ambulatory.

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Standing exercises should begin as soon as physical rehabilitation exercises are initiated. Support is provided as needed while the patient is placed in a standing position to ensure loading/weightbearing of the pelvic limbs and correct positioning of the feet. This is performed for 2 to 5 minutes 3 times daily. After the patient is able to maintain a standing position and the confinement period is over, exercises to challenge balance, such as weight shifting and wobble board exercises, may be instituted.5 Ambulation is allowed at slow paces in patients with voluntary motor function. Assisted sling walking or underwater treadmill hydrotherapy is used to unload weight while allowing ambulation. An underwater treadmill can facilitate active movements while supporting the dogâ&#x20AC;&#x2122;s body weight through buoyancy (FIGURE 8). For example, a dog bears 91% of its body weight with the water at the level of the hock. Increasing the water level to the height of the stifle decreases weight bearing to 85%, while adjusting the water to the level of the hip decreases it to 38%.

Furthermore, the resistance of the water helps to improve or build muscle strength. Water is much more resistant than air, making water exercise a better strengthening exercise than land walks. Hydrostatic

pressure of the water has been shown to reduce edema and swelling, which may be of benefit in nonambulatory patients. Walking or swimming in water also improves general circulation. The water should be kept warm to provide the beneficial effects of heat to body tissues. Heat increases the elasticity and blood flow of tissue and also helps to relax the patient.

Strengthening exercises can be added when ambulation improves and after the kennel rest period.

Strengthening exercises may consist of walking up and down inclines, weaving around obstacles, walking on varying textures (eg, sand, tall grass), stepping over objects of varying size (for proprioceptive awareness), and sit-to-stand exercises (FIGURE 9).5 Neuromuscular electrical stimulation may be beneficial to increase tissue perfusion, decrease pain, and delay the onset of muscle atrophy. It can be used to delay the onset of neurogenic muscle atrophy in patients with lower motor neuron disease. It is contraindicated over the incision following a hemilaminectomy. Neuromuscular electrical stimulation should be applied to affected muscle groups once daily for 15 minutes until the patient is ambulatory (FIGURE 10).4 A minimum of 3 weeks of physical rehabilitation is recommended. However, the degree of success with physical rehabilitation varies greatly, and a successful outcome may take several months.5 SUMMARY IVDH is one of the most common diseases causing paresis in dogs. It may result in a variety of clinical signs, ranging from spinal hyperesthesia to paraplegia. Many dogs recover if given the proper

FIGURE 8. Underwater treadmill.

FIGURE 9. Cavaletti poles.

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FIGURE 10. Neuromuscular electrical stimulation.

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treatment and nursing care. The skilled veterinary technician is an essential part of the veterinary team and may possess the nursing skills needed to get these patients back on their feet again. ď Ž References 1. Lorenz MD, Coates JR, Kent M. Handbook of Veterinary Neurology. 5th ed. Philadelphia: Elsevier Saunders; 2011.

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2. Platt SR, Olby NJ. BSAVA Manual of Canine and Feline Neurology. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2004.

3. Dewey CW, da Costa RC. Practical Guide to Canine and Feline Neurology. 3rd ed. Oxford: Wiley Blackwell; 2016.

4. Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient. Vet Clin North Am Small Anim Pract 2005;35(6):13891409.

5. Millis DL, Levine D, Taylor RA. Canine Rehabilitation and Physical Therapy. Philadelphia: Saunders; 2004.

CE Test Intervertebral Disc Herniation The article you have read has been submitted for RACE approval for 1 hour of continuing education credit and will be opened for enrollment when approval has been received. To receive credit, take the approved test online at VetMedTeam.com/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. This type of intervertebral disc degeneration results in a protrusion of the annulus fibrosus into the vertebral canal.

a. Hansen type I IVDH

b. Hansen type II IVDH

c. Traumatic IVDH

d. None of the above 2. Which of the following would be an indication for conservative management of Hansen type I IVDH?

a. Animal with an initial episode of mild neurologic dysfunction

b. Animal with owner who has financial constraints

c. Animal with other medical problems precluding general anesthesia and surgery

d. All of the above 3. The recommended time frame of cage confinement with conservative management of intervertebral disc herniation is ________ weeks.

a. 1 to 2

b. 2 to 3

c. 3 to 4

d. 4 to 6 4. What is the most important aspect of conservative therapy for Hansen type I IVDH?

a. corticosteroid administration

b. NSAID administration

c. enforced kennel rest

d. physical rehabilitation 5. Hansen type II IVDH is most common in which of the following dog breeds?

a. Dachshund

b. German shepherd

c. Great Dane

d. Shih tzu

6. Hansen type I IVDH is most common in which of the following dog breeds?

a. Dachshund

b. German shepherd

c. Cavalier King Charles spaniel

d. Labrador retriever 7. Which of the following is the gold standard imaging modality to diagnosis IVDH?

a. Myelography

b. Radiography

c. CT

d. MRI 8. Which surgical procedure is known for improving retrieval of the herniated disc in thoracolumbar IVDH with minimal spinal cord manipulation?

a. Ventral slot

b. Hemilaminectomy

c. Corpectomy

d. Dorsal laminectomy 9. During underwater treadmill therapy a dog bears _______________ of its body weight with the water level at the greater trochanter.

a. 38%

b. 91%

c. 85%

d. 14% 10. _______________ is liquefaction of the spinal cord parenchyma. It is a concern for dogs with absent deep pain perception.

a. Discospondylitis

b. Myelitis

c. Meningomalacia

d. Myelomalacia

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1 Credit Continuing Education | Peer Reviewed

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M E E T T H E AU T H O R

Sarah Kolb, RVT, VTS (Clinical Practice–Exotic Companion Animals)

Rabbit Dentistry Dental disease is one of the most common reasons pet rabbits present to veterinary clinics. It can produce a wide variety of clinical signs and varies in severity. Although the underlying cause of dental disease can be congenital or traumatic, husbandry is a major influence in the prevention, onset, and treatment of dental disease. When rabbits are fed an inappropriate diet, their teeth can overgrow, resulting in malocclusions and other abnormalities. The goals of treatment are to return teeth to their normal anatomy and to control inflammation and infection, thereby returning the teeth to normal function. Veterinary technicians play a vital role in educating rabbit owners about prevention and early detection, as well as assisting veterinarians with diagnosing and treating dental disease.

Shutterstock/sirtravelalot

ANATOMY AND PHYSIOLOGY A thorough understanding of normal oral anatomy and physiology is necessary for prevention and treatment of dental disease in rabbits.

Rabbits are unique in that they have 4 maxillary incisors (101, 102, 201, and 202) and 2 mandibular incisors (301 and 401) (FIGURE 1).1–5 Two of the maxillary incisors (102 and 202) are significantly smaller and are called the peg teeth.1–5 The peg teeth are located directly behind the larger set of 2 incisors (101 and 201).1–5 The maxillary incisors are typically shorter than the mandibular incisors and have a longitudinal groove on the labial surface that runs the length of each incisor tooth.1–5

Lloyd Veterinary Medical Center Iowa State University

Sarah is a primary care/exotics registered veterinary technician and wildlife care clinic supervisor at Iowa State University Lloyd Veterinary Medical Center. She is pursuing her bachelor in applied sciences degree in veterinary technology from St. Petersburg College. She is a licensed wildlife rehabilitator, certified veterinary technician specialist (exotic companion animal), and national certified veterinary technician. Her interests include avian anatomy, physiology, behavior and training, anesthesia, and exotic companion animal enrichment and husbandry.

CLIENT EDUCATION Veterinary technicians play a vital role in educating rabbit owners about prevention and early detection of dental disease. Rabbit owners should be instructed to feed unlimited high-fiber foods.

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When the jaw is at rest, the mandibular incisors are situated behind the first larger set of maxillary incisors in occlusion with the peg teeth, and the cheek teeth do not touch (FIGURE 2).1–5 Lack of contact between the molars is due to anisognathism, meaning the mandible is narrower than the maxilla.1,5 Rabbits do not have canine teeth.1–4 Instead, there is a space between the incisors and premolars called the diastema (FIGURE 1).1–5 The premolars and molars are anatomically identical, making

FIGURE 1. (A) Cheek teeth. (B) Diastema. (C) Four maxillary incisors, including the 2 smaller peg teeth situated directly behind the larger set of incisors, and 2 mandibular incisors. Note the chisel-like appearance of the incisors and the occlusion of the mandibular incisors to the peg teeth.

FIGURE 2. Craniocaudal view of rabbit skull. When the jaw is at rest, the cheek teeth do not touch. This is due to anisognathism (mandible is narrower than the maxilla).

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differentiation of each tooth challenging.2 Thus, the premolars and molars are simply called the cheek teeth.2 The dental formula for a rabbit is I2/1, C0/0, P3/2, and M3/3, for a total of 28 teeth.1–5 Rabbit teeth are cylindrical and have a natural curve as they grow.1,5 The occlusal surface of the maxillary cheek teeth curves buccally, and the occlusal surface of the mandibular cheek teeth curves lingually.1 They are aradicular; that is, both the incisors and the cheek teeth have open apices, never forming true tooth roots.1 Rabbit teeth are also elodont, meaning that they continually grow throughout the life of the rabbit.1 Germinal tissue, located at the apices of the teeth, continuously forms enamel to cover each tooth as the teeth constantly grow.3 Because of this, there is no anatomic difference in the tooth above or below the gum line.3 The enamel is free of pigment, resulting in white teeth.1 Rabbits have a blind spot directly in front of their mouth, so they rely on sensitive vibrissae on their lips to find food.4 Food items are grasped with prehensile lips, bitten off or chopped with the incisors, and moved to the cheek teeth by the tongue.4,5 Occlusal surfaces of the cheek teeth are irregular, providing a rough surface for grinding coarse, fibrous material. Normal side-to-side grinding movements of the jaw during mastication keep the teeth worn down to a proper length.1,5 Teeth wear down approximately 2 to 2.4 mm per week, depending on the rate of tooth growth and attrition.1,5 CAUSES OF DENTAL DISEASE Dental disease results from any anatomic or physiologic abnormality that interferes with eruption or wear of incisors, cheek teeth, or both. Causes of dental disease are categorized as congenital or acquired. Congenital causes are conditions present at birth. Acquired dental disease is not inherited but rather the result of external factors.2 Congenital causes include prognathism, brachygnathism, and other jaw malformations.2 For example, a malformation of the incisors may cause improper wear of the cheek teeth, eventually leading to the development of sharp points and overgrowth of the cheek teeth. Alternatively, a malformation of a cheek tooth may cause improper occlusion of other cheek teeth or the incisors, causing improper tooth wear and overgrowth.

Acquired causes of dental disease include trauma, systemic disease, neoplasia, and improper nutrition.2 Jaw fractures and broken teeth are common traumas.2 If not healed properly, changes in the jaw and occlusion of the teeth may result, leading to improper attrition of teeth and subsequent dental disease. Systemic disease that causes any change in

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Rabbits without sufficient roughage in their diet may not be grinding their teeth properly, predisposing them to overgrown teeth and dental disease. a rabbit’s normal diet and eating patterns may lead to dental disease.1–4 A systemic disease characterized by altered calcium levels may result in changes in jawbones and altered tooth placement.3,5 Improper nutrition is the most common cause of dental disease in pet rabbits.3 Improper food items prevent normal tooth wear, eventually leading to dental disease.3,5 CLINICAL SIGNS Rabbits are a prey species, so they tend to hide clinical signs of illness until they are remarkably debilitated.2 Clinical signs of dental disease are directly related to the severity of the disease.2 If the dental disease is mild, the rabbit may not show any signs. However, once one tooth is affected, over time, the dental disease will affect all the other teeth. The following clinical signs may be associated with dental disease in rabbits: ÆÆ Changes in eating ability or pattern, including anorexia, decreased food intake, selectiveness of food items, and difficulty holding food in mouth. Oral pain can cause anorexia and difficulty eating.1–3,5,6 Malocclusions may make eating certain food consistencies difficult, causing the rabbit to choose smaller, softer food items over fibrous hay.3 Malocclusions of the mandibular cheek teeth may cause the tongue to become trapped, making it difficult or impossible for the rabbit to move food toward the cheek teeth.3 ÆÆ Changes in fecal output, size, and appearance. Changes in eating patterns result in changes in fecal output.1,2 ÆÆ Excessive drooling or area of wetness or hair loss under the chin. Pain can cause excessive salivation, resulting in drooling.2,3 Malocclusions may limit the rabbit’s ability to completely close its mouth, which also results in drooling.2,3 ÆÆ Nasal discharge. Elongation of roots of maxillary teeth, especially the maxillary incisors, may irritate sinuses, resulting in nasal discharge.3 ÆÆ Matting of hair on forelimbs. Rabbits are

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fastidious groomers. Matting of the hair on the forelimbs indicates that the rabbit is grooming discharge from the eyes, nose, or mouth.1,6 ÆÆ Epiphora or exophthalmos. The roots of the maxillary incisors are close to the tear ducts (FIGURE 3).3 If elongated, the roots will partially or completely occlude the nasolacrimal duct, resulting in excess tearing and wetness around the medial canthus of the eye.3,6 ÆÆ Facial masses or swellings. Facial masses and swellings can be caused by abscesses forming around the affected teeth.1 Masses or swellings palpated along the ventral mandible could indicate elongated roots of the mandibular cheek teeth.1 ÆÆ Bruxism. Bruxism (ie, tooth grinding) is an indication of pain.1,3 ÆÆ Uneven occlusal surfaces of the cheek teeth.

Although a thorough oral examination can be performed only with the rabbit under sedation, uneven occlusal surfaces may be observed during an oral examination by using a bivalve nasal speculum or an otoscope cone (FIGURE 4).1,2,6 DIAGNOSIS Dental disease is diagnosed by obtaining a thorough patient history and by performing a physical examination and endoscopic oral examination with the patient under sedation, blood analysis, and radiography.1 Patient History A thorough history should be obtained for every patient. Information on a patient’s eating habits may reveal early dental disease.1 Rabbits without sufficient roughage in their diet may not be grinding their teeth properly, predisposing them to overgrown teeth and dental disease.1

FIGURE 3. The roots of the maxillary cheek teeth are in close proximity to the periorbital space.

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The tooth roots, jawbone, periodontium, nasolacrimal canal, and intra-alveolar portion of the teeth can only be examined radiographically.

Physical Examination Every rabbit that presents to the veterinary hospital should undergo a physical examination that includes an oral examination. Early detection of dental disease increases the probability of successful treatment.

The success of performing an oral examination on an unsedated rabbit varies depending on the stress level and cooperation of the rabbit. If dental disease is suspected, a more thorough oral examination should be performed with the patient under anesthesia.1 Rabbits with advanced dental disease commonly present with anorexia, pain, gastrointestinal stasis, or other secondary illness. These patients require anesthesia to perform a thorough, stress-free oral examination.

The incisors are examined by pulling the lower lip down with the thumb and forefinger of one hand while using the thumb and forefinger of the other hand to pull the upper lip up and aside in similar fashion (FIGURE 5).

The length, color, shape, quality of enamel, and occlusal edge can be assessed. Healthy incisors will be white and cylindrical, with a horizontal, chisel-shaped edge. When the jaw is at rest, the mandibular incisors should meet the peg teeth directly behind the maxillary incisors.1 The oral cavity of rabbits is small, making it impossible to examine the cheek teeth without instrumentation and sedation. A cursory examination of the cheek teeth may be performed without sedation by using a bivalve nasal speculum or an otoscope cone. By inserting the speculum or cone through the diastema into the oral cavity, the occlusal surface of the cheek

teeth may be briefly examined, although the viewing window is limited. The lateral and dorsal surfaces of the cheek teeth are difficult or impossible to evaluate in this fashion, and small dental lesions are easily missed.1 An endoscope may also be used to view the cheek teeth. As with an otoscope cone or bivalve nasal speculum, the endoscope does not allow a thorough evaluation of the cheek teeth in an awake patient. Endoscopes may also be easily damaged if the rabbit chews on the delicate equipment. However, the endoscope permits substantial magnification, making small lesions easily detectable. Another advantage of the endoscope is the ability to take pictures, allowing owners and other members of the veterinary team to see the oral cavity.1

FIGURE 4. Demonstration of the use of a bivalve nasal speculum during an oral examination on a rabbit.

FIGURE 5. The incisors are examined by pulling the lower lip down with the thumb and forefinger of one hand while using the thumb and forefinger of other hand to pull the upper lip up and aside.

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Blood Analysis Blood analysis is indicated if systemic disease is suspected or anesthesia is required for a dental procedure.5 Radiographic Examination Radiography is an essential diagnostic tool that should be performed for all patients with suspected dental disease.1 The bulk of the teeth and the supporting structures is below the gumline, hidden from view during gross oral examination. The tooth roots, jawbone, periodontium, nasolacrimal canal, and intraalveolar portion of the teeth can only be examined radiographically. Changes to these structures account for 80% of dental disease.1 Radiographs also provide the veterinarian with information on treatment options and long-term prognosis.

Proper positioning of the patient is vital for correct interpretation of radiographic images.1,2,7 It may be necessary to sedate or anesthetize the patient to reduce patient stress and to obtain correctly positioned, symmetric radiographic images of the skull.1,2,7 The standard projections needed for thorough

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evaluation of the oral cavity of the rabbit are a laterolateral skull view, dorsoventral or ventrodorsal skull view, and right and left 40º oblique skull views.1,2,7 BOX 1 provides positioning guidelines.

The laterolateral view often yields the most valuable information regarding dental disease.1,7 The incisor teeth, cheek teeth, and supporting structures are easily evaluated for malocclusions.1,7 The appearance of the bone surrounding the teeth may also be assessed.1,6 The dorsoventral view is particularly helpful for evaluating the palatal and buccal margins of the cheek teeth and the zygomatic bone.1,7 Oblique projections of the skull are useful for separating individual cheek teeth of the mandible and maxilla, which are directly superimposed in laterolateral views.1 In 2009, Boehmer and Crossley introduced the use of anatomic reference lines when evaluating dental radiographs (BOX 2).1,7 Computed tomography (CT) is becoming a widely accepted alternative to dental radiography in specialty and academic facilities.1,2 CT allows 3-dimensional reconstruction of the skull, viewing of finer detail than can be seen on radiographs, and isolation of areas or teeth of interest.1 CT is especially advantageous

BOX 1 Positioning Guidelines for Dental Radiography in Rabbits7,8 RADIOGRAPHIC VIEW

POSITIONING GUIDELINES

Laterolateral

 Place the patient in lateral recumbency. If applicable, position the affected side nearest to the cassette.  Pull front limbs caudally and extend the head. Use foam pads, rolled hand towels, or tape to assist with positioning the rabbit’s skull perfectly horizontal to the table.  Vertically position ventral margins of the mandible and both eyes. In some patients, it may be useful to open the mouth slightly with a small cotton prop to separate the occlusal surfaces of the maxillary and mandible teeth.

Dorsoventral

Ventrodorsal

 Place the patient in sternal recumbency. The front limbs can remain in natural position; ensure they are out of the x-ray beam.  Use sandbags to apply gentle pressure to the back of the patient’s neck to ensure the head is not tilted ventrally. Use tape or foam wedges on either side of the head to prevent rotation if necessary.  If positioned correctly, both of the patient’s eyes will be horizontal to the table.

 Place the patient in dorsal recumbency. Use V-trays and foam wedges to prevent rotation of the patient.  Pull the front legs caudally. Use foam or rolled hand towels to support the neck of the patient and tilt the patient’s nose toward the table top, achieving a ventrodorsal position.  The ventral lower jaw should be horizontal to the table top.

Right and left 40˚ oblique

 Place the patient in lateral position.  Pull the front legs caudally and extend the head.  Rotate the patient’s head 40˚ away from the table.  Repeat with the patient in lateral position on the opposite side.

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for evaluating intranasal structures, surrounding soft tissue structures, abscesses, and neoplasia.1 TREATMENT Treatment of dental disease consists of returning teeth to their normal length, restoring normal occlusion, extracting diseased teeth, and treating associated abscesses.

Crown Height Reduction Crown height reduction can often be curative in the beginning stages of dental disease when accompanied by diet correction and other preventive measures.1–3 However, in cases of moderate to severe dental disease, crown height reduction procedures will need to be performed repeatedly.1-3 Overgrown incisors or cheek teeth should be trimmed using a dental bur or trimming forceps (FIGURE 6A) designed specifically for crown reduction.1-3 Nail trimmers, rongeurs, and other manual cutting tools should never be used to perform crown height reduction.2,3 Root damage, tooth fractures or splinters, and abnormal regrowth

are likely to occur when using improper equipment.2,3 Crown reduction performed without sedation or anesthesia is difficult and often done blindly, resulting in missed sharp points or spurs and injury to the gums, cheeks, or tongue.1-3 Rabbits with moderate to severe dental disease should be anesthetized, allowing crown reduction and reshaping to be performed with a low-speed dental bur while protecting soft tissues with bur guards and dental spatulas.1–3 (FIGURE 6B) Tooth Extractions Tooth extraction with the patient under general anesthesia is indicated for any tooth that is loose, infected/abscessed, fractured, or severely maloccluded.2 Extractions can be performed intraorally or extraorally, depending on the difficulty of the extraction based on the accessibility of the diseased tooth and the size of the patient.2 Tabletop mouth-gag positioners, oral speculums, cheek dilators, spatulas, a low- to high-speed dental handpiece with a cheek guard, dental burs, and

BOX 2 Boehmer and Crossley Radiographic Anatomic Reference Lines1,7

Lateral view, normal anatomy A black line (A) extends from the tip of the nasal bone to the occipital protuberance. The roots of anatomically normal maxillary cheek teeth will not extend past this line.

The white line extends the height of the tympanic bulla. A second black line (B) runs parallel to the first, extending from the rostral end of the hard palate to one-third of the height of the tympanic bulla. The occlusal surface of the cheek teeth will appear to match this line in healthy rabbits. A yellow line (C) highlights the mandibular cortical bone. The roots of anatomically normal mandibular cheek teeth will not extend past this line.

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Dorsoventral view, normal anatomy A black line (A) extends from the lateral margin of the mandibular incisors to the medial margin of the mandibular ramus on the same side.

Another black line (B) extends from the lateral margin of the mandibular incisors to the lateral wall of the tympanic bulla on the opposite side.

Cheek teeth should not extend outside of these reference lines. Two yellow lines (C) highlight the medial cortex of the mandible, which should appear straight, smooth, and symmetric.

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Lateral view, abnormal anatomy: Note the overgrowth of the cheek teeth that extend past all 3 reference lines. The occlusal surface of the teeth does not match the reference line. The mandibular cortical bone is not straight and smooth in appearance. Also note the overgrowth of the mandibular incisors.

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Treatment of dental disease consists of returning teeth to their normal length, restoring normal occlusion, extracting diseased teeth, and treating associated abscesses.

Crossley incisor and molar luxators are specialized equipment used to assist in positioning and tooth extraction (FIGURE 6).2,6 Analgesia and nutritional support must be provided after surgery to any patient undergoing a tooth extraction procedure.6 Treatment of Abscesses Abscesses on a rabbit’s head or jaw are often associated with the periapical area of an infected incisor or cheek tooth.1 In rabbits, mandibular abscesses are more common than maxillary abscesses.1 Often, abscesses present as palpable masses. Occasionally, an abscess is detectable only on radiography or CT.1 Treating a rabbit with an abscess can be difficult because the pus has a remarkably thick-to-solid consistency.1 Primary A

B

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treatment of an abscess is to remove the cause, which is 1 or more infected teeth.1 Further treatment of the abscess varies by veterinarian preference but may include repeated lancing and flushing of the abscess, systemic antibiotics, complete surgical excision of the abscess, and antibiotic bead impregnation.1,3 Analgesia and nutritional support may be indicated in patients that have an abscess.1 PREVENTION Proper nutrition and husbandry are essential for the prevention of dental disease. Rabbit owners should be instructed to feed unlimited high-fiber foods.3,5 Grass, a good-quality timothy hay, and fibrous, green, leafy vegetables are favorable foods that are high in fiber and encourage the grinding motions of the jaw that benefit attrition of the teeth.7 Rabbits require a diet that provides enough calcium for sufficient mineralization of their continually growing teeth and surrounding bone structures, but not so much calcium that urinary tract disease is a risk.5 The ideal amount of dietary calcium for a rabbit is 0.5% to 1.0%.5 Barn-dried hay may not contain as much vitamin D as sun-dried hays.5 Alfalfa hay is very high in calcium.7 It is a good choice for rapidly growing young rabbits but should not be fed as a sole source of hay for adult rabbits.5 If possible, rabbits should be allowed to graze outside on a variety of grasses and weeds while basking in the sun, which helps prevent a vitamin D deficiency.5 Pellets are not a necessary part of a rabbit’s diet. If pellets are fed, they should be timothy hay based, not alfalfa based.5 Pellets require a less desirable chewing motion of the jaw, not the grinding motion required

C

G

D

E

F

FIGURE 6. Common dentistry equipment. A. Molar cutters. B. Spatulas. C. Tabletop mouth gag. D. Mouth gag and cheek dilators. E. Dental handpiece and cheek guard. F. Dental burs. G. Incisor luxator.

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for fibrous grasses and hays.5 Mixed-cereal foods are also not recommended because it is impossible to prevent rabbits from selectively feeding.5 In addition to proper nutrition practices, owners can be educated about acquiring their pet rabbits from breeding stock without a history of dental disease in their lineage. Growing rabbits are especially susceptible to congenital

malocclusions and metabolic bone disease if fed inappropriate, low-calcium food items early in life.5 CONCLUSION Dental disease is profoundly common in pet rabbits.

Although it cannot be prevented in all pet rabbits, feeding a high-fiber diet and providing objects to encourage chewing are positive preventive practices.

Pain Assessment in Small Mammals Sarah Kolb, RVT, VTS (Clinical Practice–Exotic Companion Animals)

Recognizing and assessing pain in small mammals can be challenging. As prey species, small mammals mask signs of illness and injury, especially when in an unfamiliar environment. The International Association for the Study of Pain (IASP) describes pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”1 Lichtenberger and Ko indicate any “animal should be assumed to be experiencing pain in any condition expected to produce pain in human beings.”2 Therefore, when working with a patient, it is reasonable to ask yourself, “Would this illness or procedure cause me to feel pain?” If your answer is yes, then it is likely the illness or procedure will also cause the animal pain.

History and husbandry information about the patient should be obtained from the owner using open-ended questioning techniques upon arrival at the veterinary clinic. Since the patient will most likely be masking any signs of illness or discomfort, information obtained from the owner about how the animal has been acting in its normal environment will be helpful. The interview process also allows time for the animal to become accustomed to the veterinary clinic setting.

Observation of the patient during the interview or in a quiet room before handling may reveal signs of pain or discomfort.

If a small mammal is unable to mask clinical signs of pain and discomfort, it should be considered severely debilitated.

Assessing pain in small mammals can be a difficult task, but it is not impossible. There is no one objective way to tell if a small mammal is feeling pain, as individual animals display different clinical signs. These signs may include anorexia, lethargy, lameness, reduced grooming, abnormal vocalizations, aggression when usually docile, or any deviation from normal behavior.3 Many small mammals in pain hide under bedding or substrate.

They also segregate themselves from their cage mates, positioning themselves on opposite ends of their enclosure.

An increase in the frequency and depth of respirations or rapid, shallow breathing is also a sign of distress.

Bruxism, a loud tooth grinding, is a common clinical sign of pain in small mammals. The animal may be less active or even completely immobile. It may display a hunched posture, arch its back, or press its abdomen to the floor.3

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Various species and individuals have different pain responses and pain tolerance.4 Rats have a harderian gland that secretes red, porphyrin tears when they are ill or stressed, giving the appearance of bleeding eyes. Guinea pigs and rodents may display piloerection. Guinea pigs, which normally give highpitched squeals when handled, also tend to be quiet during handling while painful. Ferrets are reluctant to curl up while resting and commonly squint their eyes. Other animals, frequently rodents, spend more time than normal curled up and may have bulging eyes. Overgrooming, chewing at the location of pain, and self-mutilation are observed in small mammals, most commonly in rodents and sugar gliders.

Appropriate multimodal analgesia techniques can and should be used in small mammals. The veterinary technician oath states, “I solemnly dedicate myself to aiding animals and society by providing excellent care and services for animals, by alleviating animal suffering, and promoting public health.”5 Veterinary technicians play an integral role in recognizing pain in patients and act as patient advocates to alleviate pain and suffering in all animals.

References 1. Merskey H, Bogduk N, eds. IASP Taxonomy. International Association for the Study of Pain. iasp-pain.org/ Taxonomy#Pain. Accessed October 2016.

2. Lichtenberger M, Ko J. Anesthesia and analgesia for small mammals and birds. Vet Clin Exotic Anim Pract 2007;(10):293-315. doi:10.1016/j.cvex.2006.12.002 3. Pollock C. Pain management in small mammals. LafeberVet; April 23, 2011. lafeber.com/vet/pain-managementin-small-mammals/. Accessed October 2016.

4. Manicinelli E. Recognising and managing pain in small mammals and exotics. Vet Times November 1, 2011. vettimes.co.uk/article/recognising-and-managing-pain-insmall-mammals-and-exotics/. Accessed October 2016.

5. The Veterinary Technician’s Oath. Oklahoma Veterinary Technician Association. okvta.org/veterinarytechnicians-oath.html. Accessed October 2016.

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Annual physical examinations of pet rabbits assist in early detection of dental disease. Veterinary technicians play a critical role in educating rabbit owners about early clinical signs of dental disease, as well as diagnostic modalities and treatment options for a pet rabbit with suspected dental disease.  References 1. Boehmer E. Dentistry in Rabbits and Rodents, West Sussex, UK: Wiley Blackwell, 2015.

2. Lennox A. Diagnosis and treatment of dental disease in pet rabbits. J Exotic Pet Med 2008;17(2):107-113.

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3. Brown S. Rabbit dental disease. VeterinaryPartner.com. 2001.

VeterinaryPartner.com/Content.plx?P=A&A=472. Accessed October 2016.

4. O’Malley B. Clinical Anatomy and Physiology of Exotic Species, St. Louis, MO: Elsevier Saunders; 2005.

5. Harcourt-Brown F. Textbook of Rabbit Medicine, Woburn, MA: Reed Educational and Professional Publishing; 2002.

6. Harcourt-Brown F. The progressive syndrome of acquired dental disease in rabbits. J Exotic Pet Med 2007;16(3):146-157.

7. Boehmer E, Crossley D. Objective interpretation of dental disease in rabbits, guinea pigs and chinchillas. Use of anatomical reference lines. Tierarztliche Praxis 2009;37:250-260.

8. Lavin LM. Radiography in Veterinary Technology. 3rd ed.

Philadelphia, PA: Elsevier; 2003.

CE Test Rabbit Dentistry The article you have read has been submitted for RACE approval for 1 hour of continuing education credit and will be opened for enrollment when approval has been received. To receive credit, take the approved test online at VetMedTeam.com/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. The space between the incisors and premolars is called the/a

a. diastema.

b. buccal space.

c. lingual space.

d. malocclusion.

6. Which of the following is a congenital cause of dental disease in rabbits?

a. Jaw fracture

b. Neoplasia

c. Improper nutrition

d. Prognathism

2. The dental formula for a rabbit is:

a. I1/1, C0/0, P2/3, M3/3

b. I2/1, C0/0, P3/2, M3/3

c. I1/1, C1/1, P3/2, M3/3

d. I2/1, C0/0, P2/3, M3/3

7. Masses or swellings palpated along the ventral mandible could be an indication of

a. elongated mandibular incisors.

b. elongated mandibular cheek teeth.

c. uneven occlusal surface of cheek teeth.

d. labial points on occlusal surface of cheek teeth.

3. The term _________ means the teeth have open apices, never forming true tooth roots.

a. aradicular

b. hypsodont

c. bruxism

d. anisognathism 4. The term _________ means the teeth continually grow throughout the life of an animal.

a. aradicular

b. hypsodont

c. elodont

d. attrition 5. In a normal, healthy rabbit, the teeth wear down _____ mm per week.

a. 0–0.4

b. 1–1.4

c. 2–2.4

d. 3–3.4

8. _________ skull radiographic views often yield the most valuable information regarding dental disease in rabbits.

a. Laterolateral

b. Dorsoventral

c. Right oblique

d. Left oblique 9. _________ is not high in fiber and does not encourage the grinding motions of the jaw that benefit tooth attrition in rabbits.

a. Timothy hay

b. Apples

c. Green leafy vegetables

d. Grass 10. Rabbits that eat a diet high in calcium are at risk for

a. decreased mineralization of teeth.

b. decreased mineralization of bones.

c. congenital malocclusions.

d. urinary tract disease.

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M E E T T H E AU T H O R

Luxating Patellas: Pathology and Treatment Options Patellar luxation (PL) is one of the most common hindlimb orthopedic pathologies seen in dogs and has been diagnosed in many other mammalian species as well. PL is the displacement of the patella out of the distal femoral patellar surface, or trochlea. The patella can displace, or luxate, medially or laterally.

Patients with PL can present with varying degrees of lameness, ranging from asymptomatic to non–weightbearing on an affected limb. Clinical signs often depend on the grade of luxation, progression of the condition and subsequent joint capsule changes, amount and frequency of exercise, and any concurrent orthopedic disruptions. Treatment options can include surgery (followed by physical rehabilitation) or conservative care that consists of pharmacologic and supplemental intervention, lifestyle changes, and physical rehabilitation.

ANATOMY The patella is a sesamoid bone encapsulated within the patellar ligament, which itself is the distal aspect of the quadriceps femoris muscle tendon where it inserts onto the tibial tuberosity. The quadriceps femoris muscle is composed of 4 muscle group heads: the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. These heads join in the common tendon, and all act as stifle extensors, while the rectus femoris also flexes the hip.

The extensor apparatus of the stifle includes the quadriceps femoris muscle, the patella, and the patellar ligament and its attachment on the tibial tuberosity. When the extensor apparatus is correctly aligned with the underlying axial skeleton, the patella is stable and acts as a pulley, directing

Maria Maddox, LVT, CCRP, AMCP Maria Maddox, LVT, CCRP, AMCP, received her bachelor’s degree in biology from Bryn Mawr College and her associate’s degree from Bel-Rea Institute of Animal Technology. She is a licensed veterinary technician in Colorado, Nevada, and Georgia, and earned her certification as a Canine Physical Rehabilitation Practitioner (CCRP) in 2006 from the University of Tennessee. She is the Membership Chair of the Academy of Physical Rehabilitation Veterinary Technicians. Her professional interests include nutrition and hospice care. Having recently moved to Georgia, she is starting her own business, subcontracting with local veterinarians to provide physical rehabilitation to their canine and feline patients.

PATELLAR LUXATION is the displacement of the patella out of the distal femoral patellar surface, or trochlea. This radiograph shows a preoperative ventrodorsal view of a 13-month-old female spayed Labrador retriever diagnosed with bilateral grade IV lateral patellar luxation.

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the line of action for the quadriceps tendon. During neonatal and adolescent growth, normal axial alignment causes the patella to exert pressure on the articular cartilage of the trochlear groove, creating a groove with adequate depth and width as the animal grows.

Luxation of the patella can result from trauma or congenital abnormalities; congenital malformations are far more common. A congenital cause of PL is more frequent in dogs regardless of age, weight, or breed; a study from 1994 reported that 82% of the dogs in the study had congenital luxations.1 Because of the prevalent congenital nature of the disorder, breeding of patients diagnosed with atraumatic patellar luxations is strongly discouraged. Reports in the literature are conflicting about whether PL is congenital or traumatic in cats.2,3 The medical consensus is that multiple anatomic abnormalities and combinations of abnormalities can lead to PL. Common possible underlying musculoskeletal abnormalities that may contribute to PL include torsion and/or bowing of the distal femur, tibial deformity, displacement and/or atrophy of the quadriceps, femoral epiphyseal dysplasia, shallow trochlear groove with hypoplastic or absent trochlear ridges, hip dysplasia, and rotational instability of the stifle joint.4,5 CLINICAL SIGNS PL is graded on a scale of I to IV to differentiate the severity of clinical signs noted during physical examination (BOX 1). Grade I PL is commonly an incidental finding on routine examinations, with the patient presenting asymptomatically and no reported

BOX 1 Grades of Patellar Luxation Grade I The patella can be manually luxated with the limb in extension, but it returns to the trochlear groove immediately when pressure is released. Flexion and extension of the joint should be normal. Spontaneous luxation of the patella during normal joint motion rarely occurs.

Grade II The patella may be manually luxated or may spontaneously luxate with flexion of the stifle. The patella remains luxated until it spontaneously returns to the trochlear groove with active extension of the stifle or until it is manually replaced.

Grade III Patella is continuously luxated but can easily be manually replaced. Patella does reluxate spontaneously when manual pressure is removed.

Grade IV Patella is continuously luxated and cannot be manually reduced.

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clinical indication by the owner. Dogs presenting with grade II or III luxation usually have a history of occasional skipping, intermittent or consistent hindlimb lameness, and reluctance to jump or walk down a slope. Owners may have noted hearing and/or feeling a “click” or “pop” when the dog walks or have observed that the dog will suddenly stop during a walk and look back toward the affected limb or even kick it out to the side or caudally, which reduces the luxation without further intervention. Patients with grade IV luxation often present with continual lameness or are non– weightbearing on the affected limb, with weight shifted cranially at a stance and while walking. They often cannot completely extend the affected stifle during ambulation.

Such clinical signs can vary with patient age, with mean ages at diagnosis averaging between 2 and 5 years for dogs6-8 and 37 and 40 months for cats.2,3 Signs can worsen if body weight is increased, articular cartilage damage is present, and if there is concurrent cranial cruciate ligament (CCL) rupture.9 Affected cats have shown signs of intermittent locking of the stifle after extension and can have a shuffling or crouching gait.

Affected cats do not always present with lameness.2 DIAGNOSIS Diagnosis of PL is primarily based on palpation of the affected stifle. Radiography can help determine the presence and degree of limb deformity and aid with planning of any surgical realignment procedures (FIGURES 1 and 2). Radiography can also determine the degree of osteoarthritis if present. On radiography, the patella will be visualized outside of the trochlear sulcus in grade III and IV PL and may be visualized within the trochlear sulcus in grade I and II luxations.4 OCCURRENCE Medial patellar luxation (MPL) is much more common than lateral patellar luxation (LPL) in both dogs and cats, regardless of age or size of the patient. Studies have shown that MPL occurs in 83% to 95% of all dogs diagnosed with PL,10,11 whereas LPL is more common in large- and giant-breed dogs than in small-breed dogs, with a prevalence up to 33% in giant breeds.1 However, PL is most commonly diagnosed in toy and miniature breed dogs, including Chihuahuas, Maltese, miniature poodles, Pekingese, Pomeranians, and Yorkshire terriers, as well as mixed breeds5,9,12,13 and Labrador retrievers.7 Evidence of sex predilection is contradictory. Some studies show male-to-female ratios of anywhere from 1:110 to 1.8:17 to 1:1.9.5 A theory suggests that PL may be more common in male large-breed dogs and female small-breed dogs.5 On average, about 50% (range, 41% to 83%) of dogs diagnosed with MPL have bilateral luxations.14,15 In 2 studies of cats, the occurrence of bilateral PL

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was 38% in one3 and 81% in the other.2 Concurrent CCL disease in patients diagnosed with PL has been discussed and studied; rates range from 4% to 41%.12,16 The predominant theory behind this occurrence is that CCL ruptures or tears (commonly abbreviated A

B

as CCLRs) may result from chronic PL because of malalignment of the extensor mechanism of the stifle and internal rotation of the proximal tibia.

One study found that dogs with bilateral MPL had a higher grade of luxation in the stifle that had the C

Patella

Patella Patella

Toggle buttons used during tightrope procedure D

Patella

Tibia

Toggle buttons used during tightrope procedure

FIGURE 1. Radiographs of a 7-year-old male neutered domestic shorthaired cat that presented with chronic left hindlimb lameness. Medial patellar luxation (MPL) was diagnosed and treated conservatively until lameness worsened to grade 4/5. At the time of radiography, the patient was diagnosed with grade III MPL in the left hindlimb and grade II MPL in the right hindlimb. (A) Preoperative ventrodorsal view showing bowing of the tibia. Radiologist reported remodeling of the margin of the medial femoral trochlea on the left hindlimb. Note the medial location of the patella. (B) Preoperative mediolateral view. (C) Postoperative ventrodorsal view after a mini tightrope procedure, medial retinaculum release, and lateral fascia imbrication. CCL rupture was diagnosed during surgery. (D) Postoperative mediolateral view.

Courtesy of VCA Animal Specialty Center of South Carolina, Columbia, South Carolina

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B

C

Patella

Patella

Patellas

Bony degenerative changes FIGURE 2. Radiographs of a 13-month-old female spayed Labrador retriever diagnosed with bilateral grade IV lateral patellar luxation with no CCL rupture. The patient was treated with bilateral trochlear wedge resections and tibial tuberosity transpositions, followed by physical rehabilitation. (A) Preoperative ventrodorsal view. (B) Preoperative mediolateral view of left hindlimb. (C) Preoperative mediolateral view of right hindlimb. Courtesy of Dr. Beck at Backlund Animal Clinic, Omaha, Nebraska

concomitant CCL rupture and that “dogs with grade IV MPL were significantly more likely to have concomitant CCLR than were dogs with all other grades of luxation.”12 Conversely, researchers for another study stated that “an association between the grades of patellar luxation and CCL ruptures was not observed.”5 TREATMENT OPTIONS Surgery Treatment options for PL depend on the grade of luxation, any concurrent conditions (such as CCL disease), presenting signs and lameness, patient’s age, and any financial or personal limitations of the owner.

Surgery is usually recommended for grade III or IV luxation; however, when it comes to recommending surgery for grade II PL, preferences vary among veterinarians, even board-certified surgeons. Some sources recommend surgery for all grade II PLs,17,18 while others recommend conservative treatment for patients with grade II luxations that present with mild and infrequent lameness and mild, nonprogressive osteoarthritis.19,20 Surgery is often recommended for puppies or young adult dogs to reduce premature wearing of the articular cartilage in the stifle joint and

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for patients that have active growth plates to reduce the likelihood of skeletal deformities worsening.4 The goal of surgery is to realign the quadriceps’ extensor apparatus, thereby stabilizing the patella in the trochlear groove to reestablish normal joint function.

Doing so may minimize progression of underlying orthopedic disease, such as osteoarthritis. Most sources agree that PL surgery should involve more than one surgical correction technique to maximize the successful return of function. These techniques can broadly be divided into two classes: bone and soft tissue reconstruction (BOX 2). Patients with grade IV luxations will probably need multiple corrective surgeries,21 and owners should be fully informed about this likelihood. Postoperative care includes restricted activity and guided physical rehabilitation exercises to maximize healing and minimize postoperative injury or complications. After a tibial tuberosity transposition, radiography should be performed at 6 to 8 weeks to evaluate bone healing before the patient is allowed to engage in increased activity.

Conservative Management Conservative treatment for PL usually consists of pain management with analgesics and nonsteroidal

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anti-inflammatory drugs, as well as various nutraceuticals as prescribed by the veterinarian. Cryotherapy, or the application of cold packs, to the stifle can help provide analgesia and reduce inflammation and is easily performed at home by clients who are educated on proper application methods (BOX 3). Other physical rehabilitation modalities that focus on analgesia can be performed, such as transcutaneous electric nerve stimulation (TENS), acupuncture, laser therapy, or therapeutic ultrasound.

After pain control, conservative treatment focuses on strengthening hindlimb muscles, especially those on the opposite side of the direction of luxation. For MPLs, muscle strengthening focuses on the gluteals and biceps femoris, while for LPLs, it focuses on the sartorius and adductor muscles.

Overall hindlimb strengthening can be accomplished by the following exercises (FIGURES 3 and 4): ÆÆ 3-legged and 2-legged stands ÆÆ Inclined stand ÆÆ Half-squat/sit to stand ÆÆ Full-range sit to stand ÆÆ Uphill walking ÆÆ Side stepping ÆÆ Walking on an underwater treadmill with the water level varying between stifle and mid-thigh height

BOX 2 Surgical Interventions for Medial Patellar Luxation 1. Bone reconstruction a. Trochleoplasty (defined as modifying the shape of the trochlear groove) i.

Trochlear wedge recession ii.

Trochlear block recession iii.

Trochlear sulcoplasty

iv. Trochlear chondroplasty in dogs younger than 6 months

v. Medial ridge elevation wedge trochleoplasty

b. Tibial tuberosity transposition 2. Soft tissue reconstruction a. Release of retinacular tissues i.

Desmotomy ii.

Capsulectomy b. Imbrication of retinaculum c. Excision of redundant retinaculum d.

Antirotational sutures e.

Quadriceps release

Exercises should be performed on surfaces with good traction and stability to prevent the patient from slipping. The first 4 exercises listed can be made more challenging by having the patient perform them on an unstable surface, such as a thick foam surface or on an inflated balance ball or peanut roll/physio roll.

Stretching the soft tissues on the same side of the luxation further helps in the attempt to realign the pull on the patella. The terms “passive range of motion” (PROM) and “stretching” are sometimes used interchangeably, but these are not actually the same exercise. Range of motion (ROM) exercises take the joint and soft tissues through the available range, while stretching takes the tissues beyond the normal ROM.22 When PROM is performed on a patient, the joint is held at the end range for only a few seconds; stretches are held for 15 to 30 seconds. (For some examples of PROM and stretching exercises, see todaysveterinarytechnician.com.)

Patients being treated conservatively for PL by physical rehabilitation professionals typically go for treatment 1 to 3 times a week, with the owner performing prescribed therapeutic exercises at home daily. Treatment may continue a few months, until the patient is asymptomatic and has been reexamined by the veterinarian. If during this time the patient develops increased lameness or pain, reexamination by the veterinarian is necessary to rule out any complications, such as a CCL rupture or damage to the meniscus.

Although the primary goals of physical rehabilitation professionals treating PL patients are to decrease pain, increase flexibility of the soft tissues, increase muscle strength, and normalize gait, these professionals also need to look at the whole patient and not simply focus on the hindlimbs. Patients with PL commonly have compensatory postures (FIGURE 3), including increased cranial weight shift and increased flexion of the lumbosacral, coxofemoral, and stifle joints.23 To address compensatory patterns, trunk- and corestrengthening exercises are also warranted, as are massage and soft tissue mobilization techniques.

Postoperative Physical Rehabilitation The general goals of physical rehabilitation are as follows: ÆÆ To return the patient and affected body part to maximum functional activity through the use of noninvasive modalities and exercises and to minimize or reverse functional impairments ÆÆ To preserve surgical interventions ÆÆ To maintain or improve quality of life ÆÆ To prevent future injury ÆÆ To educate clients After surgery to correct PL, the goals of a physical rehabilitation program change as the patient

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BOX 3 Cryotherapy Cryotherapy is the therapeutic application of low temperatures. It has the following effects:  Causes vasoconstriction, thereby decreasing blood flow  Reduces inflammation and edema  Decreases nerve conduction, thereby producing mild analgesia  Decreases nerve conduction velocity, thereby reducing muscle spasm  Decreases cellular metabolism and permeability Cryotherapy is applied predominantly during the acute phase of inflammation; this inflammation can be caused by injury or exercise in the course of healing.

Cryotherapy is particularly effective during the first 24 to 72 hours after injury/acute inflammation.

Methods of application:  Cold packs  Ice-water circulating compression bandages  Ice-cup massage or ice-water immersion  Vapocoolant spray (rarely used in veterinary medicine) Cold packs should be malleable so they can conform to anatomic surfaces. Crushed ice in a sealed plastic bag works well. Commercially available freezer packs can be reused several times with proper sanitation and care.

Apply cold packs to the treatment area for 15 to 25 minutes at a time, with a towel or cloth between the ice pack and the patient’s skin to prevent skin damage.

A wet towel will allow more rapid cooling than a dry towel. Inspect the skin every minute to ensure the tissue is not being cooled too quickly (FIGURE A).

Ice cup massage incorporates cold therapy with a light massage. It is easiest to use paper drinking cups (FIGURE B).

FIGURE A. Cryotherapy being provided by cold pack compress and ice cup massage.

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 Fill cups halfway or two-thirds full with water and freeze.  Once the water is completely frozen, peel back the paper from the top of the cup to expose a half-inch to 1 inch of ice.  Holding the cup, place the ice on the patient and make small, overlapping circles with the ice over the desired area.  The ice will melt during treatment, so lay a towel under the patient to absorb the water.  Be careful to avoid incisions that the veterinarian has recommended stay dry.

This method may not be possible on patients with thick coats of fur and can be difficult to perform adequately over bony/thin joints, such as the tarsus. Treatment can be performed for 10 to 25 minutes; inspect the skin as for cold pack therapy.

Cryotherapy can be used 3 to 6 times a day, ideally with at least 1 hour between treatments to allow tissue to warm back up. Continue cryotherapy daily until the injured tissue is in the subacute phase of healing. Cryotherapy can also be used after exercise to prevent or minimize reactive swelling and pain.

Contraindications to cryotherapy:  Presence of peripheral vascular disease  Application over areas with decreased sensation  Open wounds  Hypertension (cold may increase blood pressure if it is applied to the majority of the body at the same time, so avoid immersing a patient in an ice water bath if there is any history of hypertension)  Potential for peripheral nerve injury with prolonged exposure  History of cold hypersensitivity response/cold reaction

FIGURE B. Patient receiving ice cup massage while recovering from MPL surgery.

todaysveterinarytechnician.com PEER REVIEWED

progresses through each phase of tissue healing: the inflammatory phase, the reparative phase, and the remodeling/maturation phase.22 Inflammatory Phase The inflammatory phase occurs during the first 3 to 5 days after injury or surgery and is characterized by an acute vascular response focused on hemostasis of the surgical site. It is also characterized by a cellular reaction focused on the use of neutrophils and macrophages to “clean up” the site through debridement, phagocytosis, matrix synthesis, and cell recruitment and activation. During the first week after surgery, cryotherapy is used to reduce inflammation (BOX 3). The patient’s activity should be restricted to slow leash walks lasting 5 to 8 minutes for elimination purposes 3 to 4 times a day. Patients should be prevented from running, jumping, playing, and having access to stairs.

Gentle PROM exercises should be performed on the stifle and hip, putting them through gentle flexion and extension to maintain flexibility, prevent adhesion formation between soft tissues, and help maintain joint capsule health. PROM exercises should be performed 3 to 4 times a day, for 5 to 10 repetitions on each joint.

Massage of the quadriceps, hamstrings, and gluteal muscles before PROM helps warm up the tissues and can aid in relaxation and analgesia; massage can be performed for 5 to 15 minutes 3 to 4 times a day.

Reparative Phase The reparative phase occurs within 3 to 14 days after injury and is characterized by the cellular response of fibroblasts and endothelial cells. The fibroblasts synthesize collagen and create new extracellular matrix components. The endothelial cells work to form new capillaries and help produce granulation tissue. During weeks 2 and 3, cryotherapy can be discontinued or applied only as needed, and the use of warm packs can be started. Warm packs can be wrapped around the stifle and held in place for 10 to A

B

C

15 minutes 2 to 3 times a day before activity, massage, or PROM exercises. Massage and PROM exercises as performed in week 1 should be continued.

Patients may begin static weight-shifting exercises (wherein the patient is not being asked to move limbs during the exercise), which can include 3-legged stands and assisted standing on a balance board.

Activity restriction should be continued, and it is recommended that all therapeutic exercises be performed while motion is limited to the sagittal plane only.22 After suture removal and recheck by the veterinarian 10 to 14 days after surgery, the veterinarian may recommend increasing leash walks by an additional 5 to 10 minutes as tolerated by the patient.

Remodeling Phase The remodeling phase occurs 2 to 3 weeks after injury, with tissue strength continuing to increase over the course of 1 year. This phase is characterized by remodeling of collagen fibers to orient in parallel to lines of stress as well as becoming crosslinked, thereby strengthening the healing tissue. This is the phase in which scar tissue is formed.

Ideally, the patient will be consistently placing partial weight on the surgical limb by the end of 2 weeks. For 3 to 8 weeks after surgery, therapeutic exercises will continue to be added and modified, with the goals of maintaining or gaining normal ROM of the stifle, increasing weightbearing of the surgical limb, and building muscle strength of the hindlimbs and core stabilizers. After a examination by a veterinarian and stifle radiography at 6 to 8 weeks after surgery, the physical rehabilitation professional will likely modify the patient’s exercise program to include more challenging exercises and increase walks with the goal of returning to full activity.

PROGNOSIS AND COMPLICATIONS Overall prognosis for surgically corrected PLs is good to excellent. The most common complications are patellar reluxation, implant complications (ie, pin migration), tibial tuberosity fracture avulsion, and wound dehiscence.

D

E

FIGURE 3. (A) A 4-year-old female spayed Pomeranian displaying a compensatory stance. Note the cranial placement of the left hindlimb and mild external rotation of the right hip. This stance is caused by the patient shifting its weight to the right hindlimb to reduce weightbearing on the left. This patient was diagnosed with grade III lateral patellar luxation in the left hindlimb and grade II medial patellar luxation in the right hindlimb. (B) Patient performing incline stand with front limbs on a stable surface, therefore shifting more weight onto hindlimbs. (C) Caudal view of incline stand. Note that the patient has shifted more weight to the right hindlimb, thereby reducing weightbearing on the more symptomatic limb, the left hindlimb. (D) Patient performing 3-legged stand exercise on a balance disc. Note that therapist is supporting the patient’s trunk to prevent the patient from falling off the disc. (E) Patient standing on a BOSU ball to provide more challenge while standing on all 4 limbs and for weight-shifting exercise.

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Overall postoperative complication rates range from 17% to 51%.10,11 It has been theorized that increased body weight is a risk factor for postoperative complications7; higher grades of luxation are also at higher risk. The prognosis for long-term outcome among PL patients in general, regardless of treatment option, worsens the older the patient is at onset and as the grade of luxation and severity of clinical signs increase.17 To my knowledge, no major studies have assessed whether outcomes differ substantially between PL patients treated conservatively with physical rehabilitation and those treated surgically; most studies focus on surgical techniques and outcomes.

Gibbons et al did report that the “long-term outcome for dogs with grade 1 and 2 patellar luxations treated non-surgically was less favourable than that for dogs treated surgically.”7 Thirty-three percent of the limbs included in that study were treated nonsurgically. Of these, 86% had excellent to good outcome and 14% had fair or poor outcome. However, the study did not elucidate the treatment parameters for patients treated nonsurgically. Loughin et al found that 47% of their feline patients that were treated nonsurgically had excellent outcome.2 They stated that “lameness may not be a good indicator of the need for surgical correction and it seems prudent to recommend a period of nonsurgical management (rest and analgesics)

FIGURE 4. This patient is in a “half-sit” or “half-squat” posture.

The therapist is using her leg as an elevated surface for the patient to sit on to perform this therapeutic exercise.

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prior to surgical intervention, particularly in cats in which signs of lameness have been present for < 2 months.”2 Environmental changes at home can help patients recover from surgery and help reduce chances of further injury on non–surgically repaired limbs. Clients should be encouraged to keep the pet’s nails well trimmed and clip any long interdigital fur from the bottom of the paws to maximize traction while walking. Clients who have only wood, linoleum, or other slick flooring at home can be instructed to lay out rubber-backed throw rugs or yoga mats to help prevent their pet from slipping.

Blocking access to stairs and couches or beds that the pet is used to jumping onto should be discouraged.

Having overweight or obese patients lose weight before surgery or even after surgical recovery is an excellent lifestyle change that increases life expectancy and reduces the negative effects of osteoarthritis.24 CONCLUSION Patellar luxation is a common orthopedic condition diagnosed in dogs. It is more common in toy and small breeds, with the patella more likely to luxate medially.

Physical rehabilitation can play an important role in helping patients recover after surgical correction and can be a realistic option for patients that are not surgical candidates. Physical rehabilitation after surgical correction for PL attenuates muscle atrophy and significantly improves weightbearing by 8 weeks after surgery.25 When tailoring a physical rehabilitation program to the needs of a specific PL patient, physical rehabilitation professionals must consider any surgical interventions the patient has received. Patients that have had bony reconstruction corrective techniques are usually treated with more conservative, low-impact therapeutic exercises during the first 6 to 8 weeks of postoperative recovery to minimize the possibility of hardware migration, avulsions, or fractures. Concurrent CCL rupture or hip dysplasia may alter the recommended rehabilitation exercise program and add challenges to the program.

Veterinary technicians and nurses should also be familiar with surgical interventions performed on their patients and be able to answer clients’ general questions regarding the initial recovery period in the hospital and after discharge. Clients should be encouraged to seek a consultation with a certified physical rehabilitation provider to maximize their pet’s recovery and return to function, as well as to minimize any potential complications after a PL surgical repair.

Veterinary technicians and nurses should be proficient in describing the activity restrictions prescribed by the veterinary surgeon and educate their clients in different lifestyle changes that can beneficial for their pet.  To see the references for this article, please visit todaysveterinarytechnician.com.

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CE as needed, when needed.

FEATURE

ESTABLISHING TRUST The Fear Free mission is to alleviate fear, anxiety, and stress in pets and educate and inspire the people that care for them. When we incorporate Fear Free techniques, our patients learn to trust us, and we are able to provide them with better medical care.

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FEATURE

FEATURE

M E E T T H E AU T H O R

The Veterinary Technician’s Role in Implementing Fear Free

Shutterstock.com/Tyler Olson

WHAT IS FEAR FREE? The Fear Freesm initiative was created by Dr. Marty Becker, “America’s Veterinarian.” Its mission is to alleviate fear, anxiety, and stress (FAS) in pets and educate and inspire the people that care for them. With the guidance of a diverse advisory panel, it is a collaboration among specialists in multiple disciplines ranging from veterinary behavior, anesthesia, oncology, and internal medicine to animal welfare and training. What we all have in common is the desire to improve animal health and welfare.

Fear Free provides online and in-person continuing education programs and a certification program for veterinary professionals. The guiding principle of Fear Free is that pets need veterinary professionals to look after not only their physical well-being but also their emotional well-being.

Fear Free provides tools, protocols, procedures, and guidelines on how to reduce FAS in patients and thus in clients and veterinary team members.

Currently, Fear Free certification is available only for individuals (BOX 1).

However, starting in 2018, veterinary hospitals will be able to become Fear Free certified. The process will be similar to American Animal Hospital Association accreditation.

WHY BECOME INVOLVED? ÆÆ Better care. When we incorporate Fear Free techniques, our patients learn to trust us, and we are able to provide them with better medical care. ÆÆ Better medicine. Patients that are more relaxed and calm during diagnostic tests will have more accurate results. How many times have you had to disregard test results because of the stress level of your patient? Examples include hyperthermia, hyperglycemia, hypertension, tachycardia, leukophilia, and inability to evaluate orthopedic lameness because of stress-induced adrenaline release. ÆÆ Making our jobs easier. When our patients are eager to see us and are relaxed and calm, it is easier for us to provide needed veterinary care efficiently and effectively.

Debbie Martin, LVT, VTS (Behavior) Veterinary Behavior Consultations, LLC, Austin, TX

Debbie has been a full-time registered/licensed veterinary technician since 1996 and worked in private practice for more than 14 years. Since 2005, she has been the animal behavior technician for Veterinary Behavior Consultations, LLC. She assists Kenneth Martin, DVM, DACVB, during behavior consultations.

Debbie is also a co-owner of TEAM Education in Animal Behavior, LLC. She is a contributing author and coeditor of the textbook Canine and Feline Behavior for Veterinary Technicians and Nurses.

She is also a coauthor of the book Puppy Start Right: Foundation Training for the Companion Dog and the Karen Pryor Academy course “Puppy Start Right for Instructors.” She is honored to be representing veterinary technicians on the Fear Free executive council.

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The Veterinary Technician’s Role in Implementing Fear Free

You might be thinking, “The way we do things here is fine. We use treats at times with our patients and provide excellent patient and client care.” You are right—you may already be using some Fear Free techniques and doing a great job of creating a relaxed and calm environment. However, with its diverse advisory panel of passionate and distinguished animal professionals, Fear Free offers a learning experience that can take your patient care to the next level.

Fear Free is about staying on the cutting edge. The Fear Free community, educational library, and toolbox routinely provide new information and resources to continue our learning and advance our skills. It is an exciting time to be involved in veterinary behavior science as new research is being published constantly.

MAIN FEAR FREE CONCEPTS The focus of Fear Free is on preventing FAS in every patient. Young and inexperienced animals may show the best response. However, Fear Free techniques and concepts should be used with all patients, whether they are relaxed and happy to be in your care or afraid and displaying avoidance or aggression.

I wish there was a simple formula to make every visit for every patient Fear Free. However, there is no one way to make each visit a Fear Free experience.

Individual animals and clients have individual preferences.

The first step is noting these preferences in the pet’s emotional medical record (see COMMUNICATION).

Some of the key concepts of implementing Fear Free while providing medical care include

BOX 1 Benefits of Registration for Fear Free Certification Program  Online certification program (9 hours of RACE-approved continuing education)  Online implementation guide (3 hours of RACE-approved continuing education)  Fear Free educational library  Fear Free toolbox: downloadable marketing tools, drug charts, and more  Private Facebook group  Fear Free podcast series with RACE-approved continuing education  Welcome kit  Monthly newsletter  Preferential pricing on preferred products  Additional RACE-approved continuing education courses offered on a complimentary basis or at discounted rates RACE, Registry of Approved Continuing Education.

For more information, visit fearfreepets.com.

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communication, considerate approach, gentle control, and touch gradient. Creating a plan of action for each patient can be a quick process that saves time and creates a more pleasant experience for the veterinary healthcare team, the patient, and the client.

Communication Being able to recognize signs of a relaxed or stressed patient is critical to creating a Fear Free environment (BOX 2). Some signs can be subtle. We must constantly assess and reassess the patient throughout the veterinary hospital experience. When working with a patient, think of it as a 2-way conversation. Listen to what the patient’s body language is telling you and adjust the conversation accordingly to prevent the patient from escalating. It can be as simple as changing to a different treat or pausing for a second to let the patient acclimate to your touch before proceeding.

Keep an emotional record alongside the medical record for each patient. Document what worked for the patient so that during the next visit, the same techniques can be incorporated. Information that might be recorded includes the types of rewards that were effective, where the patient preferred to be examined, or the way a procedure was performed. For example, a note in the emotional medical record might read: “Highvalue reinforcers: canned cheese and canned dog food.

Prefers to stand on a mat on the floor while having his nails trimmed. Works best to trim the rear feet first, then progress to the front feet.” During the patient’s next visit for a nail trim, the technician will have an initial plan for care and the client will be impressed with your thoughtfulness.

Considerate Approach As defined by the Fear Free certification program, considerate approach encompasses the interaction between the veterinary team, the patient, and inputs from the environment while veterinary care is being administered. For example, when first interacting with a cat or dog, considerate approach would involve avoiding direct eye contact or leaning over the pet, turning sideways to appear less threatening, moving smoothly and calmly (fast motion can be unsettling for animals), allowing the pet to approach first, and tossing or handing treats to the pet (when medically appropriate to do so).

Creating a relaxing and pleasant experience also entails setting up the environment with the patient and client in mind. Consider the perception of the hospital from their points of view. Providing nonslip surfaces for pets to stand on, incorporating calming scents and/ or pheromones, minimizing noises and using calming sounds, using LED lighting instead of fluorescent lighting, and using disinfectants with very little odor can help create a veterinary “spa” atmosphere to relax and calm not only dogs and cats, but also people.

todaysveterinarytechnician.com

Gentle Control As defined by the Fear Free certification program, gentle control is how the veterinary team comfortably and safely positions the patient to allow the administration of veterinary care with minimal restraint. It is often the restraint that the animal finds frightening, not the actual procedure. Incorporating distraction techniques (BOX 3) while providing gentle guidance and support to an animal allows many procedures to be performed safely with minimal restraint and fewer team members.

Touch Gradient Touch gradient is a term used in the Fear Free certification program to describe how to touch canine and feline patients to minimize FAS during veterinary procedures. Touch gradient encompasses both gentle control and considerate approach. It has 2 components: 1. Maintaining continuous hands-on contact with the patient through the entire procedure or examination, when possible 2. Acclimating a patient to an increasing level of touch intensity while continuously measuring the patient’s acceptance and comfort When working with large animals, such as horses, we are advised to keep our hands on them all the time so they know where we are and to avoid startling them. We can apply this same technique to our feline and canine patients to make for a more relaxed visit.

By gradually working through a procedure and responding appropriately to the animal’s response, we can minimize the amount of FAS the animal experiences, minimize the amount of restraint needed, and reduce the number of team members needed to perform a procedure. To see a video on use of touch gradient, gentle control, and considerate approach with a dog for an ear cleaning, visit todaysveterinarytechnician.com.

FEATURE

PLAN OF ACTION Before starting a procedure, take a moment to create a plan of action. This will help make the experience more efficient and successful for everyone. Creating a plan of action for procedures includes the following: 1. Assess the patient ÆÆ Observe and note body language and behavioral indicators of FAS ÆÆ Continuously reassess throughout the procedure 2. Assess yourself ÆÆ Are you using considerate approach? ÆÆ Ask for help if you are feeling uncomfortable 3. Assess the environment ÆÆ Set up the environment to be patient friendly ÆÆ Remove stressors in the environment 4. Create a veterinary plan for care ÆÆ Identify reinforcers ÆÆ Rank most to least important procedures ÆÆ Plan least to most aversive procedures ÆÆ Identify stopping or pause points ÆÆ Consider the 3 Ws (where, who, what) When creating the veterinary plan for care, first determine a reinforcement hierarchy for the patient. What does this patient enjoy that could be used as a possible distractor during a procedure or reinforcer after the procedure? Referring to the emotional medical record can help in planning, but reassess the patient’s response at every visit.

Next, rank procedures as most to least important.

The veterinarian will be responsible for determining this hierarchy.

Then rank the most important procedures as least to most aversive. Determine whether there are stopping points for breaks in the procedure and what behavioral indicators for this patient will be considered stopping points. A general guideline is 3 seconds/3 tries for dogs

BOX 2 Common Behavior Signs of Fear, Anxiety, and Stress in Cats and Dogs1 Obvious Signs

Subtle Signs

 Freezing

 Cowering/crouching

 Avoiding eye contact

 Lifting paws

 Lowering or flattening of ears

 Blinking slowly or squinting

 Self-grooming

 Dilated pupils

 “Shaking off”

 Growling

 Showing hypervigilance/inability to settle

 Shifting eyes

 Hiding  Hissing

 Licking lips

 Tail flicking or thrashing (cats)

 Closing mouth tightly or pulling mouth back  Pacing

 Taking treats roughly, being pickier than usual about treats, or refusing treats

 Panting

 Yawning

 Lifting lip/snarling  Tucking tail  Trembling

 Staying close to the owner

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and 2 seconds/2 tries for cats. The premise is that if a dog struggles or stops accepting a distraction for 3 seconds, then try something else. Three well-tolerated attempts/tries (or 2 tries for cats) is the general limit before you should consider rescheduling or sedation (see PRIORITIZING PROCEDURES). Depending on the emotional medical record of the patient, these guidelines may be modified to fewer attempts or less time.

Once you have a high-level reinforcer for the patient, a plan for the order in which you will perform the procedures, and stopping or pause points, consider the 3 Ws. ÆÆ Where will you perform the procedure? The examination room, treatment area, or housing area?

It is usually better for patients to remain where they are most comfortable. If the pet is there for a preventive care visit, can the procedure be performed in the examination room? If the pet is staying in the hospital, an examination room (if available) can provide a quiet and less active environment.

BOX 3 Possible Distractors or Reinforcers for Cats and Dogs Every pet has individual preferences. Discovering what a pet enjoys allows us to associate desirable things with experiences, thus creating a positive and pleasant memory. The following lists provide some examples of potential reinforcers.

Treats  Commercially available cat and dog treats, including crunchy, semimoist, and freeze-dried  Canned cat or dog food  Meat-based baby food (no onions or garlic)  Canned cheese  Green olives (cats)  Bonita flakes  Deli meat Toys  Wand toys for cats  Long tug toys for dogs  Plush toys  Balls of appropriate size  Paper balls for cats  Food storage toys (caution: for some dogs, such a toy may be a long-lasting resource in their possession and may evoke a need to guard it from people) Other  Catnip  Brushing  Petting  Happy talk (caution: human anxiety is often communicated through intonation; pets can pick up on this and become more nervous)

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ÆÆ Who will be present? If possible, it is usually best for the owner or familiar person to be present. ÆÆ What do you need to make the environment as pleasant as possible? What items do you need for the procedure? Get everything ready before the patient is brought to the area.

Always be willing to ask for assistance from other team members as needed for re-evaluation of the plan.

PRIORITIZING PROCEDURES Procedures can be grouped into “wants” and “needs.”2 Wants are procedures that you would like to perform today. Needs are those that must be performed today because they are vital to the animal’s immediate health and waiting any length of time would be severely detrimental.

If wants are producing FAS in the patient, it does not mean the procedure will never be performed. Instead, other options should be considered, such as being willing to reschedule. Perhaps the patient has reached its tolerance for today. Another day may be better. In the meantime, schedule some fun visits so that the patient can have a pleasant experience at the hospital. The veterinarian should consider dispensing previsit pharmaceuticals.

If rescheduling is not an option—the procedure is a need—the veterinarian should consider sedation to minimize a potentially emotionally damaging experience.

WHAT CAN YOU DO? ÆÆ Become a Fear Free–certified professional by completing the online course. ÆÆ Make Fear Free part of how you interact with every patient, every client, every visit!

Through early recognition of behavioral signs of FAS and intervention, we can prevent the escalation of fear in our patients. Thus, we can facilitate pleasant associations with the veterinary hospital and the procedures we want to perform. Creating a veterinary plan for care for each patient will help facilitate a Fear Free experience for all team members. The veterinary technician plays a vital role in implementing Fear Free.

However, Fear Free is not just about the pet’s experience in the veterinary hospital. Pets actually spend a very small part of their lives in the veterinary hospital. To create pets that are Fear Free throughout their lifetime, we must offer preventive behavior care services for our clients and patients. These services will be the subject of an article in the next issue.  References 1. Becker M. Signs of anxiety and fear. dvm360.com/sites/default/ files/images/pdfs-for-alfresco-articles/Signs_of_anxiety_fear.pdf.

Accessed May 2017.

2. Koch CS. A low-stress handling algorithm: key to happier visits and healthier pets. DVM360. August 10, 2015. veterinarymedicine. dvm360.com/low-stress-handling-algorithm-key-happier-visits-andhealthier-pets. Accessed May 2017.

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Compliance: A Team Effort PEER REVIEWED

CAREER CHALLENGES MEET THE AU TH O R

Debbie Boone, BS, CCS, CVPM

Compliance: A Team Effort

2ManageVets Consulting

Debbie has 23 years of hands-on veterinary practice management experience. She is a speaker, writer, consultant, and avid champion for animals and their healthcare providers. Her focus is developing the communication and client service skills of veterinary teams.

She is Fear Freesm Certified and a member of the Fear Free advisory board and speaker’s bureau. She is also a member of AAHA, the VHMA, and VetPartners, where she chairs the Practice Management Special Interest Group.

Debbie presents at major conferences and is the instructor for Patterson Vet Supply’s Communication and Customer Service Class. She spends her off time at the beach with her husband of 38 years and her 14-year-old shelter pup Rocky.

For years, veterinary management experts have been discussing how to get clients to comply with veterinary care recommendations.

The statistics have been studied, the numbers crunched, and strategies suggested, yet according to the 2009 American Animal Hospital Association (AAHA) Compliance Study,1 compliance is nowhere close to the goal of 90% to 100%. The struggle is real.

However, there are practices whose numbers break the benchmarks.

How do they get clients to “yes”? What do they do differently than those hospitals that are chronically looking at 30% to 50% compliance?

The following are my rules for promoting best compliance.

FIRST RULE—HAVE APPROPRIATE STAFFING This may seem out of place in a compliance discussion, but the veterinary practice must have qualified team members who understand the reasons behind the medicine and enough staff to allow them time with clients. A team that is chronically short-staffed cannot take the time needed to explain the importance of a service or product.

Customer service team members working a busy desk alone will not have the freedom to chat and build important relationships with new or existing clients. Doctors constantly facing a lobby full of impatient clients will hear the clock ticking and rush explanations. Technicians and assistants pulled in too many directions are not able to spend quality time in examination and treatment rooms or on the phone.

SECOND RULE—ESTABLISH STANDARD PROTOCOLS Fortunately for veterinary hospitals, the American Veterinary Medical Association (AVMA) and AAHA have invested time and expertise to create approved standards of care—canine and feline vaccines and diagnostics, pain control, behavior, end of life care, and more—all of which are good bases for building hospital protocols. The American Association of Equine Practitioners (AAEP) has done the same for horses.2

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Peer Reviewed

Shutterstock.com/Pressmaster

CAREER CHALLENGES

GREAT COMPLIANCE takes a great team and a consistent effort to communicate with clients.

In multidoctor practices, creating standards of care becomes more challenging because medical opinions often vary. One way to clarify a practice’s protocols is to have all the veterinarians complete an anonymous questionnaire listing what they believe to be the best medicine for common hospital procedures.

For example: A practice has 6 doctors on staff and wants to design a protocol for routine canine ovariohysterectomy. The veterinarians fill out the questionnaire, and all except 2 agree that patients should have presurgical blood analysis, be intubated, be given a preoperative physical, and have their blood pressure, heart rate, and O2 saturation monitored. One veterinarian believes that placement of an IV catheter should be routine, and the other believes postoperative pain control should always be sent home with the patient. Now the practice can begin to develop the protocol based on common beliefs. Then the practitioners can work to reach a consensus about postoperative pain control and IV catheter placement. The practice owner may have to step in and break the tie. The team can also contact a local specialist or use a tool for protocols (eg, VetCompanion.com) to discover what veterinary specialists say is best.

Either way, the practice formulates a protocol that all agree will be the minimum standard of care.

Standards of care are vital to improving client compliance. Clients engage with many team members. The team will discover that it is impossible to educate clients when multiple answers are available.

THIRD RULE—PROVIDE TEAM TRAINING Hospitals that have high compliance rates train the team to deliver a consistent message. In singledoctor practices, this message is simple—it is what the veterinarian decides is appropriate for the geographic area. If a multidoctor practice has followed Rule 2, it now has a standard of care that the team is trained to follow. Training on a consistent message and standard of care is vital.

If pet owners receive contradictory information from different team members, they will first become confused—and then mistrustful.

The most important thing we can gain with clients is trust. Consider the following scenario: A client brings in her kitten for a routine spay. Dr. Old School performs the procedure but does not include preoperative blood analysis, placement of an IV catheter, or postoperative pain control in the surgical treatment plan. The entire procedure costs $145.

Later, the same client comes back with another kitten for the same procedure, and Dr. Two Years Out performs the surgery—including preoperative blood analysis, placement of an IV catheter, fluid administration, patient monitoring, and pre- and postoperative pain control. The cost tallies $345.

Here comes the problem. The client perceives one of two options: either Dr. Old School omitted something very important and risked the pet’s safety, or Dr. Two Years Out padded the bill and charged for a lot of extras that were not necessary.

The result? Loss of trust. When quoting the cost

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Compliance: A Team Effort



PEER REVIEWED

of a feline ovariohysterectomy, the team should never have to first ask, “Which Doctor do you want to see?”

A common excuse concerning the lack of team training is the lack of time to do so. What this really means is that the practice does not have a commitment to training, because we always make time for things we believe are important. Some practices choose to close for 1 to 2 hours over lunch, lock the door, turn on the answering machine, and train their staff. These hospitals have a commitment to routinely training their team. When clients have questions, the team has the answers—and the answers are consistent.

The importance of why can never be stressed enough when training to a standard. When doctors determine what they consider to be best medicine for their practice, it is vital that they explain their basic reasoning to the team. Without this knowledge, the team may recite what they have been told, but they never can relay the reason or be passionate about the benefit to the patient or human family. As a result, clients won’t understand the need for important services, and the patient won’t receive them.

It is common for a practice to stock and display every possible parasite preventive. Not only is this poor inventory control, but it sends an inconsistent message to staff and clients that there is no clear choice. The same principle applies to preoperative blood analysis. A common question on surgical release forms is, “Do you want preoperative blood tests?” Why would we ask this of a client who has no training in veterinary medicine? Why are we not leading them based on our expertise?

Many clients are often unable to distinguish whether their new dog is male or female. It seems incongruous to ask someone that uninformed to make a medical decision about presurgical care.

FOURTH RULE—PRACTICE WITH ROLE PLAYING AND SCRIPTS Not everyone enjoys role playing, but it is an amazing tool. Anyone who has presented clients with a newly offered service knows that if you do not grab their interest in the first 2 sentences, the answer is commonly “I just want what I always get.” However, if you can quickly pique a glimmer of curiosity, you can typically provide a more elaborate explanation and gain agreement to the service for the patient. Developing a good script helps us create our “catch line.” We can work with fellow team members to find the most engaging and effective wording to use and then practice until our delivery is smooth and confident.

To best explain why we need to practice, we need to understand some neuroscience. In the books Brain Rules by John J. Medina and The Power of Habit

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TECHPOINT 

If pet owners receive contradictory information from different team members, they will first become confused— and then mistrustful.

by Charles Duhigg, we learn that our brain creates neuropathways for the things we commonly do (eg, bathing, brushing our teeth, preparing our morning coffee). If you have ever driven to work, parked your car, and suddenly realized you have no idea how you got there, you have experienced a neuropathway at work. When we create our script and practice it repeatedly, we are building a new neuropathway that will instantly be available to us when the need arises. This fluency makes us more believable to our listener because we are confident and prepared.

The negative issue with these neuropathways is that they never go away. So, when you are trying to make a change in a common protocol, be aware that your brain will continue to pull you toward the old pathway. This is why smokers and dieters relapse. As a team, it is advantageous for members to agree to help each other overcome the old pathway and hold each other accountable for creating the new one.

FIFTH RULE—BE A GOOD STORYTELLER Veterinary teams sometimes assume that clients understand more about veterinary care than they typically do. In fact, we can become very judgmental and outraged when clients ignore our advice or delay providing routine preventive care to our patients.

According to consultant Thomas E. Catanzaro, DVM, MHA, FACHE, DACHE, veterinarians often assume that pet owners are similar to livestock owners in that they understand basic animal husbandry.

Farmers are knowledgeable about how to keep their production animals healthy with vaccination, proper nutrition, and housing. Our clients often become pet owners from a different direction. Perhaps a stray wandered into their home or they walked through a pet shop or a shelter and came home with that cute critter. Therefore, they may have little or no scientifically sound knowledge about proper care.

When pet owners enter the veterinary hospital, the team attempts to educate them, sharing the science and medicine behind the protocols. We often use jargon and terms that are incomprehensible to

VETFOLIO WORK Cristi Semmler, BS, CVT, RALAT Faculty Instructor of Veterinary Technology Eastern Wyoming College VetFolio User Since 2015

Teaches 65-70 students each semester

See how Cristi puts VetFolio to work: Signing Up “At the NAVC Conference in 2015, I chatted with one of the reps at the booth. I found out that there was no subscription fee for educators, so I looked into signing up. I liked the different types of courses available. As an educator, I like to be on the cutting edge of veterinary education so I can give students a heads-up on what’s new in the industry.”

Getting Started “If I’m working on my CE, I’m usually at home. I use VetFolio to look for specific examples for my students. I’ll watch a course at home and assign it as a module in class, and ask them to bring their certificate in to show they completed it. If I tell students “This is how it is” about a certain topic, they may not take it as well from me, but coming from expert in the field, it really has weight.

We frequently use VetFolio courses to enhance the information in class.”

Becoming a Pro Pro tip: “Go into specific continuing education and search for something you’re interested in. You may need to generalize your search term a little to find what you’re looking for. I probably spent 30 hours over the Christmas 2015 break doing continuing education just because I felt like it.”

“I think the Certificate Course series are great for students to take and put on their resumes. I think it makes them look more knowledgeable in the eyes of potential employers.”

Photo credit: Sunshine Photography by Corrie Gamel

Meet Azule!

Institutional Animal Care and Use Committee Chair

Finding Her Passion • Pain management • Lab research • Educating future generations Making #Goals Completing the six-course series on veterinary forensic science & medicine and animal crime scene investigation

INDIVIDUAL AND PRACTICE SUBSCRIPTIONS AVAILABLE. SEE HOW VETFOLIO CAN WORK FOR YOU AT VETFOLIO.COM.

Compliance: A Team Effort PEER REVIEWED

owners, yet they will feign understanding to avoid appearing uneducated. Instead of overwhelming clients with complex discussions, we should tell them a story. All veterinary teams know powerful stories of how the lack of preventive care resulted in sickness and even death of an animal.

Understanding the reason people purchase reveals the need to be a great storyteller. When people make buying decisions, they like to believe they are being logical, but in reality people buy on emotion. They are looking for “What’s in it for me?”3 When veterinary teams learn to explain to clients how not giving parasite preventives and vaccines against leptospirosis and Lyme disease puts their family at risk for zoonotic disease and then tell a story of a client who contracted the disease, the client may see the importance of compliance. Use pictures to support your story. One of my favorites is an image of a child with ocular larva migrans. When a client sees the parasitic larva in the child’s eye and understands that the numberone cause of childhood blindness in the world is parasites, such a photo can be a powerful motivator to consistently give monthly parasite preventive.

When telling stories, be sure to use emotionevoking terms, such as family safety and protecting children. Pets are important members of most families. When we stop talking medically and begin telling stories that induce an emotional response, our clients will be motivated to improve their response to our offerings. Veterinary team members may believe that clients say “No” because of money, but there are other reasons. Some clients fear causing pain, others feel that we don’t care, and others still don’t understand the benefits of our services.

We have to be better at showing the benefits.

RULE SIX—REMIND AND REMIND AGAIN In 2009, an AAHA compliance study found that “Practices employing six or more client education/ communication approaches achieved significantly higher compliance than those using fewer approaches.”1 In the age of technology, the wise practice gathers email addresses and cell phone numbers and heavily leverages email and text messages. Still, nothing is more effective than the phone call. Typically, email or text reminders are sent a few weeks before services are due, a second email or text is sent a week after the service is overdue, and then a third message is sent when the service is a month overdue. The third reminder can be the phone call. It is never a bad idea to reach out again with a phone call once a service is 6 months overdue as well.

During these calls, we may discover that a pet is deceased or no longer owned by the family or

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that the family has moved to another area, which is an opportunity to keep the database current.

The language used on reminders is important.

A message that says “Your pet is OVERDUE!” just admonishes clients and makes them feel guilty—and people avoid things that make them feel bad. The wording should be, “We miss you, and our doctors are very concerned your pet is unprotected!” This says we care.

It is imperative that patient records be updated for reminder notifications. New patients that present with an illness will miss important future care if reminders are not manually entered. A computer search for “patients without reminders” is a good way to create a list of owners to call. It also helps clean up the practice database so that compliance reports are more accurate in the future.

It is also important to track compliance on remindable services. Most veterinary practice software allows for compliance reporting provided the necessary setup is done. There are also outside services that provide excellent tools for data-mining this information. If you are not tracking compliance percentages, you will be unable to monitor how effective your team is at getting patients back for needed care. Setting goals and targets for the team and then sharing the data to show success or failure is a great way to get everyone focused. When we focus on something, it seems to improve, even if we don’t think we are making a big effort. Being “front of mind” helps in compliance success.

CONCLUSION Great compliance takes a great team and a consistent effort to communicate with clients.

Share your stories of patient success and failure with each other, gather them like tools in a tool belt, and use them to educate and motivate clients. When you do, you will find compliance will improve and your patients will be happier and healthier. The goal of every general practice should be to never have to treat a preventable disease and instead work to develop a patient base that lives a long life full of the vitality that comes with on-time immunizations and diagnostics, excellent oral care, and proper nutrition.  References 1. American Animal Hospital Association. Compliance: Taking Quality Care to the Next Level. 2009. ams.aaha.org/eweb/images/ student/pdf/Compliance.pdf. Accessed April 2017.

2. American Association of Equine Practitioners. Vaccination guidelines. aaep.org/guidelines/vaccination-guidelines. Accessed April 2017.

3. Barrows S. What’s in it for me? entrepreneur.com/article/206228.

Accessed April 2017.

Peer Reviewed TOXICOLOGY TALK

TOXICOLOGY TALK

Interrupts: Toxicants Resulting in Rapid and Severe Clinical Toxicosis In the field of veterinary toxicology, numerous agents can result in severe toxicosis for domestic pets. Interrupts is a term used by the ASPCA Animal Poison Control Center (APCC) to describe an agent that can cause a sudden onset of life-threatening clinical signs. With these agents, home treatment is generally not recommended and emergency care is required even for small exposures. This article focuses on three interrupt agents to which dogs can be exposed: 5-fluorouracil (5-FU), zinc phosphide, and hops.

5-FLUOROURACIL 5-FU is an antineoplastic drug known as an antimetabolite.1 It is used in human and veterinary medicine for cancer treatment.1 Although 5-FU is available in injectable form, toxicosis in domestic pets commonly occurs from accidental exposure to topical formulations (cream or solution) ranging in concentration from 0.5% to 5%.2 Between 2010 and 2016, the ASPCA APCC had 340 documented cases involving 5-FU. Of those 340 cases, more than 90% involved pets being exposed to topical creams or solutions either by chewing products prescribed to the owner or licking the owner’s skin after application.3 5-FU is significantly toxic to rapidly dividing cells because of its interference with RNA synthesis and inhibition of thymidylate synthase, causing DNA instability.2 As a result of this mechanism of action, the gastrointestinal (GI) tract and bone marrow are sites severely affected by 5-FU.2 5-FU can also cause severe neurotoxicity. The mechanism of action is still unknown, but the metabolites of 5-FU are suspected to be the leading culprits.1,4 The most common signs associated with 5-FU toxicosis include severe vomiting and seizure activity.2,3 Vomiting can occur within minutes of exposure, with seizures developing within the first several hours.1,4 Other signs sometimes observed include ataxia, depression, tremors, cardiac changes, respiratory changes, myelosuppression, and death.1–3 Doses as low as 5 mg/kg can result in toxicosis, with doses of 40 mg/kg being fatal.2 Patients with severe toxicosis commonly die within 24 hours.2 Prognosis with 5-FU exposures is guarded; more than 50% of patients do not survive even with intensive care.1

M E E T T H E AU T H O R

Carrie Lohmeyer-Mauzy, CVT, BS ASPCA Animal Poison Control Center Urbana, Illinois

Carrie has been working as a certified veterinary technician at the ASPCA Animal Poison Control Center (APCC) since 2007. She obtained her associate’s degree in veterinary technology from Parkland College in 2003 and her bachelor’s degree in natural resources and environmental science from the University of Illinois in 2006. She worked for 2.5 years at a small animal clinic while in college and has assisted with several research projects in fish and wildlife ecology.

During her 10 years at the APCC, Carrie has gained a wealth of knowledge in the field of toxicology. She has been published in several peer-reviewed journals and is currently studying to become a board-certified toxicologist.

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Interrupts: Toxicants Resulting in Rapid and Severe Clinical Toxicosis PEER REVIEWED

shutterstock.com/Fablok

Grain soaked in 2% concentration of zinc phosphide for control of rats, mice, squirrels, muskrats, rabbits, and gophers.

Treatment of 5-FU exposures involves managing seizure activity and vomiting, as well as protection of the GI tract. Supportive and symptomatic care is also warranted. Decontamination via emesis is recommended only with recent exposures (less than 1 hour) and in asymptomatic patients.2 Diazepam alone is generally not effective in managing seizures.1–3 Phenobarbital followed by a CRI of diazepam has shown to be effective clinically in management of seizures, as has general anesthesia and propofol.3 For patients experiencing refractory status epilepticus, levetiracetam should be considered.3 ZINC PHOSPHIDE Zinc phosphide is an inorganic rodenticide commonly used to control mice, rats, rabbits, gophers, voles, and moles.5 It is commonly sold in pelleted form or mixed with grain at a 2% concentration.6 The toxic effect of zinc phosphide primarily occurs from the production of phosphine gas after oral exposure. The phosphine gas, produced by reacting with acids in the stomach, is then absorbed into the bloodstream from the GI tract or may be inhaled into the lungs as gas escapes from the stomach.5,6 Zinc phosphide that has not been converted to phosphine gas can also be absorbed from the GI tract intact.5,6 Zinc phosphide toxicosis results in organ damage, with the heart, liver, kidneys, and central nervous system being the primary targets.5,6 Irritation of the lungs and GI tract is also prevalent.6 Clinical signs include vomiting, severe GI pain, anxiety, depression, tremors, seizures, tachypnea, and increased respiratory sounds.6 Other signs may include

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diarrhea, hypersalivation, anorexia, ataxia, tachycardia, and nonspecific behavioral changes.3,7 Clinical signs most commonly develop within 15 minutes to 4 hours after the initial exposure.6,7 Death, typically caused by cardiac arrest or pulmonary edema, can occur within 1 hour and up to 72 hours after exposure depending on the total dose.5 If pets survive the initial phase of clinical signs, there is a risk of kidney and liver failure within the following 2 weeks.6 The toxic dose of zinc phosphide is not well established.

A pet that has food in the stomach may be more at risk for toxicosis because the increased production of stomach acid results in more phosphine gas being produced.6,7 With recent exposures and in asymptomatic patients, emesis should be induced, in a well ventilated area, with a central acting emetic such as apomorphine.6 Liquid antacids, such as aluminum hydroxide or magnesium hydroxide, should also be administered to help to decrease the production of phosphine gas in the GI tract.3,6 There is no antidote available for zinc phosphide toxicosis.5,6 Treatment is predominantly supportive and symptomatic care.6 It should be noted that phosphine gas, released from the patient’s stomach or vomitus, can be poisonous to humans. The presence of phosphine gas can be identified by a garlic or rotten fish odor.6 Vomitus should be quickly disposed of in an airtight container. Owners who are transporting an exposed pet to a veterinary facility should be instructed to drive with the windows down to limit exposure to phosphine gas if the pet were to vomit or eruct in the car. A human poison control center may need to be contacted if the smell of phosphine gas is detected.

Peer Reviewed

HOPS Humulus lupulus, commonly referred to as hops, is a plant used in brewing beer. The flower or cone from the female plant has lupulin glands containing resins and essential oils, which provide beer with its distinct fragrance and bitter taste.8 Hops can be found in flower, plug, or pellet form. Only about 15% of hop constituents are used in the brewing process.8 The remaining material, referred to as spent hops, is discarded.8 Dogs are commonly exposed after spent hops have been discarded in the garbage, yard, or compost pile by an owner who is home brewing.3 Hops toxicosis in dogs results in a condition called malignant hyperthermia.9 The toxic principle is unknown. Signs of toxicosis can develop within 60 minutes after ingestion.9 The most common signs observed include tachypnea, panting, hyperthermia, vomiting, agitation, anxiety, pacing, and tachycardia.3 Other frequent signs include erythema, injected mucous membranes, lethargy, diarrhea, seizures, and death.3 Significant elevation of creatinine phosphokinase and dark brown urine may also be observed.9 Management of hops toxicosis in dogs involves decontamination and management of hyperthermia through supportive and symptomatic care. Induction of emesis and administration of activated charcoal is warranted with recent exposures and in asymptomatic pets. Fluids, external cooling (fans or ice packs), and dantrolene are recommended to help manage hyperthermia.3 Hospitalization may be required for 24 to 48 hours or until clinical signs resolve.3 ROLE OF THE TECHNICIAN It is vitally important that veterinary technicians and staff members are able to recognize these agents when an owner calls with questions regarding an exposure or when the pet presents directly to the clinic after an exposure has occurred. Owners may be unaware of the seriousness of the exposure, especially if the pet is still asymptomatic.

Because of the rapid onset of life-threatening clinical signs, home treatments should be avoided and the owner should be instructed to bring the pet directly to the veterinary hospital. Instruct owners to bring any packaging or product information with them to the clinic, if available.

Veterinary technicians will be responsible for preparing for a patient who may present to the clinic in critical condition. If it is anticipated that the services of an animal poison control center will be needed, it is recommended that the call be made (when possible) while the patient is in route to the clinic so that recommended treatments can be initiated immediately upon arrival at the veterinary hospital. Veterinary technicians will also be responsible for obtaining a history, doing the initial triage, collecting blood samples, running lab work, administering IV fluids and medications, and overall monitoring of the patient’s status. 

shutterstock.com/Vaclav Mach

TOXICOLOGY TALK

HUMULUS LUPULUS (HOPS) is a plant used in brewing beer. Dogs are commonly exposed after used hops have been discarded in the garbage, yard, or compost pile by an owner who is home brewing.

References 1. Gwaltney-Brant S. Prescription drugs. In: Poppenga RH, GwaltneyBrant SM, eds. Small Animal Toxicology Essentials. West Sussex, UK: John Wiley and Sons; 2011:248-249.

2. Sayre RS, Barr JW, Bailey EM. Accidental and experimentally induced 5-fluorouracil toxicity in dogs. J Vet Emerg Crit Care 2012;22(5): 545-549.

3. ASPCA Animal Poison Control Center. Unpublished data, 2017.

4. Friedenberg SG, Brooks AC, Monnig AA, Cooper ES. Successful treatment of a dog with massive 5-fluorouracil toxicosis. J Vet Emerg Crit Care 2013;23(6):643-647.

5. Gupta RC. Non-anticoagulant rodenticides. In: Gupta RC, ed.

Veterinary Toxicology: Basic and Clinical Principles. 2nd ed.

Waltham, MA: Academic Press; 2012:707-708.

6. Dunayer E. Rodenticides. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. West Sussex, UK: John Wiley and Sons; 2011:123-125.

7. Gray SL, Lee JA, Hovda LR, Brutlag AG. Potential zinc phosphide rodenticide toxicosis in dogs: 362 cases (2004-2009). JAVMA 2011;239(5):646-651.

8. Bedini S, Flamini G, Girardi J, et al. Not just for beer: evaluation of spent hops (Humulus lupulus L.) as a source of eco-friendly repellents for insect pests of stored foods. J Pest Sci 2015;88(3):583-592.

9. Delaporte J, Means C. Plants. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. West Sussex, UK: John Wiley and Sons; 2011:159-160.

Toxicology Talk is written and reviewed by members of the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC). The mission of the APCC is to help animals exposed to potentially hazardous substances, which it does by providing 24-hour veterinary and diagnostic treatment recommendations from specially trained veterinary toxicologists. It also protects and improves animal lives by providing clinical toxicology training to veterinary toxicology residents, consulting services, and case data review.

The ASPCA APCC includes a full staff of veterinarians, including board-certified toxicologists, certified veterinary technicians, and veterinary assistants, and its state-of-the-art emergency call center routinely fields requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

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Career Success: The Long Run FINAL THOUGHTS

FINAL THOUGHTS

Career Success: The Long Run

MEET THE AU TH O R

Melissa* has been a licensed veterinary technician for over 30 years. She came to me for coaching recently because she “just wasn’t feeling it.” She felt like she had nothing left to give and was deeply concerned about that. Here was a career she once adored, but now she was thinking about leaving it.

Much of the work I do with veterinary technicians is reminding them who they are and the power they have in their own lives. Many of them have given their power away to coworkers, managers, clients, and others.

Does this phrase sound familiar? I’d be happy in my job if only _________ would change.

I have wonderful news for you. The only thing that has to change to make you happy in your job is the way you are thinking. Your thoughts create your feelings, and you can choose what to think.

I have another client who works in a newly acquired corporate practice.

There has been a fair amount of change in the practice—software systems, client pricing, standard operating procedures, leadership, staffing, staff attitudes, etc. This technician felt overwhelmed, so she reached out to me for help. I told her that she gets to choose how to think about the situation. One option is to think what many of the staff are thinking: This stinks! Everything is changing, and I hate it.

But why dwell on your disappointment and hatred?

Once my client became more aware of how she was thinking, she realized how sad they all sounded, complaining nonstop while feeling miserable and hating their jobs.

This client worked on how she wanted to think about the situation and came up with, I can still take really good care of our patients; that hasn’t changed. She modified her mindset, and that changed how she felt about it all. She told me, “Nothing at the hospital has changed. There’s still this acquisition going on, the software systems and fees are still changing, some people are leaving and some are joining the practice, and there’s still this air of negativity among the staff. But I have changed how I’m thinking about it all. Because of that, I feel better than I’ve felt in a long time!”

Julie Squires, CCFS Rekindle, LLC

Julie is a compassion fatigue specialist who brings a unique perspective and approach to support the sustained energy and passion of animal workers. Her company, Rekindle LLC, offers onsite compassion fatigue training to veterinary hospitals, animal shelters, lab animal research facilities, and other animal organizations.

Julie has 25 years of experience within the veterinary field and with leading organizations. She has developed and executed training, workshops, and 1:1 coaching for major companies in the animal health industry. She obtained her certification as a compassion fatigue specialist through the Traumatology Institute.

Julie’s clients also gain from her experience as a certified life coach and corporate wellness specialist.

“ When you change the way you look at things, the things you look at change.”

—Dr. Wayne Dyer *Name has been changed.

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todaysveterinarytechnician.com FINAL THOUGHTS

shutterstock.com/ESB Professional

Being successful and having longevity in veterinary medicine is absolutely connected to how well you choose to think about it, and also how well you are taking care of yourself.

Being successful and having longevity in veterinary medicine is absolutely connected to how well you choose to think about it, and also how well you are taking care of yourself.

Create a paradigm shift. We think that we are either taking care of others or we’re taking care of ourselves. But those efforts are not mutually exclusive.

In order to take care of others, you have to take care of yourself. There’s no way around it, unless you don’t want to do this work for long or you want to harbor enormous amounts of resentment and anger. I don’t want that for you, and I know you don’t want that either.

How are you creating space for yourself in your life?

It’s time to connect to the part of you that is who you really are. Not you the human doing, but you the human being.

This space might look like quiet time, time in nature, exercise, creativity, unplugging from technology, meditation, journaling, playing music, reading inspiring books, etc. It’s anything that connects you to yourself and makes you feel replenished.

Have a plan. What are your aspirations? Do you want to be a supervisor, teach, or secure a job in industry? Do you want to work in lab animal, shelter, emergency, or specialty medicine? Do you want to become board-certified in a certain specialty or stay exactly where you are, doing exactly what you’re doing (which is totally fine, by the way)?

If you want a new challenge, then reach out to someone who is doing what you want to do and ask questions.

As a veterinary assistant, I knew I wanted to get into industry, so I went to conferences and talked to the manufacturer representatives and eventually landed some interviews. This led me to working for a veterinary distributor.

Increase your value. How else would you like to serve your patients and clients? Maybe you want to offer nutritional or grief support. Look into ways to become certified in areas that pique your interest. Dog training, dental care, and weight management are specialties in which technicians can truly excel and that are often neglected within many practices. Search out those areas where you can take ownership of a niche, and make it yours!

Step away from the negativity. You don’t have to look hard to find people complaining.

It’s everywhere: at work, on Facebook and other social media outlets, even on the nightly news. Just opt out, walk away, close the page, or change the channel, but do what you need to do to shield yourself from it. We think we’ll feel better if we all get together to complain about something or someone, but if you pay attention, you’ll most likely find that you end up feeling worse. Negativity breeds negativity.

Protect yourself from its toxic web (BOX 1).

Maintain your passion. How you feel about your work is 100% up to you. You can work in a hospice practice, animal shelter, vivarium, emergency practice, or anywhere else and completely love it. It’s all in how you think about it. Your thoughts create your life.

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Career Success: The Long Run FINAL THOUGHTS

CAREERS Deal with people. I became a veterinary technician so I could work with people, said no technician ever. Yet, in all of our roles, we must deal with people. I’ve always seen interacting with people as a technician’s superpower. Clients value your opinion and skill set. You may often be the touchpoint between them and the veterinarian.

When my dog Virgil was going through chemo, it was the technician who called me every few days to check in on him. I came to really appreciate those calls and her knowledge. She was such a valuable asset to me when I had questions for the oncologist.

Consider taking on more of a liaison role to help support your clients and veterinarians. The more value you can provide, the more job satisfaction you will have. It also helps at yearly review time to show all the value you bring to your organization.

Be an emotional adult. Being an emotional adult means taking full responsibility for how we feel. Other people are not responsible for how you feel; that’s an inside job. Your feelings come from your thoughts about circumstances (the facts), not the circumstance itself.

And ask yourself… ÆÆ What if you decided to assume that people are doing the best they can? ÆÆ What if instead of judging others for their choices in pet care, you accepted that not everyone views their pet like you do—and that is okay? ÆÆ What if you allowed others just to be who they are and stopped wishing for them to do what you wanted them to do (behave how you want, say what you want, etc)? ÆÆ What if you decided that you were no longer going to put yourself last on the list and moved yourself up to the first spot? ÆÆ What if you just loved your work, assumed responsibility for how you feel about things, and took really good care of yourself every day?

You’d feel so good, that’s what. 

BOX 1 Escaping Negative Thinking If you find yourself stuck in negative thinking, then start a gratitude practice (for some tips, see “Attitude of Gratitude” on todaysveterinarytechnician.com). Training your brain to find the good things that happen every day and appreciating them can shift the way you experience the world. Start with identifying 3 things every day for which you are grateful, and try to not repeat them. I recommend this practice at the end of your shift on your commute home, especially as a way to help you transition from a work mode to your personal time.

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Use Your Skills as a Force for Good!

Use your veterinary nursing skills as a force for good!

Located in Buffalo Grove, IL, Veterinary Specialty Center has been named a top workplace by the Chicago Tribune.

We encourage technicians to take an active role in case management, attend CE, and support them as they work toward their VTS certification.

Contact Sheila Haske at shaske@vetspecialty.com or call 847.459.7535., ext. 1515.

Learn more at vetspecialty.com/contact-us/jobs

Advertiser Index Merck Animal Health | bravectovets.com Bravecto inside front cover, 4 Merial | oravet.com OraVet NAVC | navc.com VMX 2018

back cover

6

Nestlé Purina | purinaproplanvets.com NeuroCare diet inside back cover PRN | prnpharmacal.com Duralactin Protégé Biomedical | clotitvet.com ClotIt Vet

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3

Veterinary Specialty Center | vetspecialty.com Recruitment

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VetFolio | vetfolio.com VetFolio.com

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Virox Animal Health | viroxanimalhealth.com/ Disinfectant

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Zoetis | zoetisus.com Simparica

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TO L E A R N M O R E A B O U T N E U R O C A R E A N D D I S H A A , VISIT PURINAPROPLANVETS.COM. Purina trademarks are owned by Société des Produits Nestlé S.A. Printed in USA.

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References: 1. Data on file, Merial, Inc. 2. Steinberg D, Beeman D, Bowen W. The effect of delmopinol on glucosyltransferase adsorbed on to saliva-coated hydroxyapatite. Archs Oral Biol.

1992;37:33-38. 3. Vassilakos N, Arnebrant T, Rundergren J. In vitro interactions of delmopinol hydrochloride with salivary films adsorbed at solid/liquid interfaces. Caries Res. 1993;27:176-182. ®ORAVET and SERIOUS ORAL CARE MADE SIMPLE are registered trademarks of Merial. All other trademarks are the property of their respective owners. Merial is now part of Boehringer Ingelheim. ©2017 Merial, Inc. Duluth, GA. All rights reserved. OVC15TRADEAD (02/17).