From the Exam Room to the Dental Table

Denise S. Rollings, CVT, VTS (Dentistry)

Veterinary dentistry isn’t just about cleaning teeth or getting rid of bad breath. A dental procedure is an anesthetized procedure that requires trained and educated veterinarians and veterinary technicians. Dentistry should be treated like every other anesthetized procedure that takes place in the veterinary hospital. Only veterinarians can diagnose disease, but the veterinary technician plays a major role in assisting the veterinarian. The veterinary technician assists by obtaining an accurate history, recognizing pathology and bringing it to the veterinarian’s attention. The veterinary technician can be trained to perform a proper and thorough dental cleaning and to obtain diagnostic dental radiographs. Periodontal disease is the top disease diagnosed in dogs and cats, where 80% of all dogs and cats over the age of 3 have some stage of periodontal disease. Every patient should be receiving routine dental care. The following procedures outline the steps of the dental procedure day.

The Pre-anesthetic Exam Oral History and Oral Exam: Look for and ask the owner about things, including bad breath; swollen, red or bleeding gums; excessive drooling; and changes in eating or chewing habits including dropping food, going to the food but not eating, vocalizing while eating, teeth loss and the disinterest in toys. Often, pets show no signs of pain. Find out what the pet chews on and how the family takes care of the pet’s dental needs at home. A patient may avoid a toy or a particular food due to pain, and the owner may perceive it as the pet not liking that item anymore.

Blood Work: A lot of our patients are geriatric, and we need to make sure there isn’t underlying disease. Age is not a disease. Age can predispose our patients to having coexisting disease. Ideally, lab work should be done before the day of the procedure in case there are abnormalities found. Having the lab work completed ahead of time will prevent a procedure from being cancelled the day of due to abnormalities. It will also allow the patient to be treated for the abnormalities ahead of time and allows that patient’s protocol to be tailored to his or her needs. A chemistry panel, complete blood count, +/- coagulation panel, urinalysis, chest radiographs, echocardiogram, ECG and blood pressure should be considered for evaluation.

Client Communication: It takes a person three times to hear something before it sinks in. The doctor discusses it, the technician goes over it with paperwork, and the client service representative mentions it again and offers to schedule the appointment. Hand out a dental report card, pamphlet and/or treatment plan. Greenies™ and Virbac have premade report cards so you don’t have to make your own. If you aren't ready to take on making your own, use what’s available. Don’t reinvent the wheel.

The Day of the Procedure Perform another physical exam upon admission including a temperature, pulse rate and respiration rate check (TPR) and hydration status check. Make sure you get all phone numbers and emergency contacts. Tell the owners they must be able to be reached and have someone else as back up to make decisions on their behalf. Know the owners’ wishes and have it in writing, in case of an emergency.

The technician should review the treatment plan, estimate and review consent forms, again, with the client. The treatment plan should be as accurate as possible, and the technician should go through it with the client line by line. One can use pictures, models, skulls, videos and charts to explain the procedure, pathology and importance of the treatment. There should be a low and high range on the estimate in case of a worst-case scenario. This will help prevent stress to the client and staff over unexpected expenses. Take a deposit for the low end of the estimate in the morning and take care of the difference at discharge.

The doctor and technician should review the history and lab results. An American Society of Anesthesiologist (ASA) Physical Status Scale should be assigned to each patient. A Class I would be a normal, healthy patient with no underlying disease and minimal risk. A Class II is a patient with mild systemic disease, putting him or her at a slight risk, but the animal is able to compensate. A Class III means there is an obvious disease present with moderate risk. A Class IV means the animal is significantly compromised by severe systemic disease, and there is high risk. A Class V is when there is life-threatening systemic disease presenting an extreme risk, and the patient is approaching death.

An anesthesia plan, including pain control, should be tailored for every patient based on that patient’s needs and health status. Anesthesia should not be "cookie-cutter." Pre-, intra-, post- and at-home pain medication equals a multimodal approach to pain management. Premedicants can be a sedative that will help reduce stress in the fearful patient. During the procedure, opioids allow for lower inhalant anesthesia because of the analgesic properties. Protocols should be based on the patient’s information, PE, workup status and temperament, and pre-existing conditions. As mentioned earlier, age is not a disease. An induction agent should be selected as well because all patients need to be intubated. Nerve blocks can be used intraoperatively to help reduce the amount of inhaled gas anesthesia used and help our patients have a smoother anesthetic procedure and recovery. A nonsteroidal anti-inflammatory can be considered on an individual basis.

Protecting Yourself Personal Protection Equipment (PPE): Wear eye protection! Goggles, loupes or a visor should be worn by everyone in the operatory area, as pieces of calculus, tooth, bone, blood, saliva and even broken burs become airborne and can cause an eye injury or infection. A surgical face mask that covers the mouth and nose should be worn. Anti-fog masks are helpful in preventing protective eyewear from fogging up. Appropriately fitted gloves and protective clothing, such as a surgical cap and a gown or lab coat, should be worn to prevent bacterial contamination of your clothing and hair. Consider using hearing protection if the noise of the dental unit running is bothersome.

Ergonomics is an applied science concerned with designing and arranging the things people use so that it is efficient and safe. Dentistry is a lot of small, repetitive movements that can strain our muscles, tendons and ligaments. In order to protect ourselves from fatigue and short- or long-term injury, we should practice the best ergonomics possible. Lift tables will adjust to an individual, and this allows for the arms to be parallel with the table. A dental saddle seat allows one to sit with their back straight, thighs slightly angled to the floor and gaze looking down, not bending over. Utilizing a modified pen grasp when holding instruments reduces the strain of repetitive movements. Fatigue mats can be used if one is standing for long periods of time

Patient Monitoring Nothing replaces a qualified person who can assess values, interpret changes and intervene when needed. Several parameters Full-mouth dental radiographs being performed as part of a comprehensive oral exam. Photo courtesy of Denise S. Rollings

should be monitored; however, the equipment should never be a substitute for hands-on human monitoring.

Heart Rate: Use a stethoscope to auscultate the heart sound and check the pulses manually. Pay attention and make note of the strength of the pulse. Quality is as important as quantity.

Respiration: Evaluate both quantity and quality. Respiratory failure can lead to cardiovascular failure. Check the mucous membrane color and capillary refill time. An increased respiratory rate could mean light anesthetic depth and decreased respirations could mean a deep anesthetic plane. Measures should be taken to correct both.

Blood Pressure: Hypotension is a very common complication of anesthesia but that doesn’t mean it’s OK. Hypotension needs to be addressed and corrected, as needed. Blood pressure can change due to the depth of anesthesia, shock, strength of cardiac contraction and blood volume. Systolic pressure should stay about 80-90 mmHg, and the mean arterial pressure should stay above 60 mmHg to make sure the vital organs receive adequate profusion. Intravenous fluids and decreasing anesthetic depth can help perfusion.

End Tidal Carbon Dioxide: A capnograph measures the end tidal (ET) carbon dioxide level in the patient. It allows for assessment of ventilation over time using a graphic display.

Occlusion check. Photo courtesy of Denise S. Rollings

The end tidal CO 2 should be between 35-45 mmHg. Common problems include the improper placement of the endotracheal tube, a leaking cuff of an endotracheal tube or apnea, to name a few.

Electrocardiogram (ECG): An ECG should be continuously monitored so that any changes or abnormalities in the electrical changes or heart rate can be recognized early.

Pulse Oximetry: Pulse oximetry measures the arterial oxyhemoglobin saturation. Oxygen saturation should be between 98-100%. The causes of saturation of 90% or less include hypovolemia, anemia, shock, probe becoming dislodged, low respirations or poor ventilation.

Temperature: Be sure to monitor temperature and keep patients warm. Our patients become very wet during a dental procedure and, therefore, are at risk of hypothermia. Monitor temperature throughout the entire procedure. It is easier to maintain temperature than try to warm them up once they are cold. Cold pets become hypotensive, bradycardic, and could develop arrhythmias and hypothermia, which, in turn, can decrease kidney function, prolong recovery and prolong healing. Use warm air heaters and circulating water blankets. Be sure to wrap the pet’s feet and keep them as dry as possible. Check the temperature of the warming devices as well. Do not put pets at risk for thermal burns and do not leave an unconscious animal on heat without being monitored.

Intravenous Fluids: Keep patients on an IV fluid pump to ensure they are receiving the proper amount of intravenous fluids and helping to prevent an accidental fluid overload. Monitor the fluid rate and change as needed. Use an appropriate rate of 2-10 ml/kg/hr based on health, hydration and blood loss of the patient. Decrease the fluid rate for patients with cardiac disease.

Steps to the Complete Dental Procedure There should be a qualified technician monitoring anesthesia and a qualified technician performing the dental procedure. It is not safe for one technician to be doing both. Neither job can be performed correctly or safely if one person is doing both.

Start with a pre-intubation exam. Check the occlusion of the patient before intubation. Once the patient is intubated, the endotracheal tube will prevent the mouth from closing. Take pictures of the occlusion so there’s a reference to look at, if attrition is found on the complete oral exam. Note any asymmetry of the head and muscles, look for draining tracts, and check lymph nodes and skin around the mouth. Open the mouth to check the range of motion before induction.

Once the pet is under anesthesia, take photos before cleaning the teeth. Check all surfaces of the teeth and note any calculus, plaque and missing teeth. Check the buccal mucosa, tongue and palate for any abnormalities, including granulomas, chewing lesions, lacerations, ulcerations or oral masses. Rinse the oral cavity with 0.12% chlorhexidine solution. This reduces the number of bacteria the staff and patient are exposed to during the procedure. Leave the solution on for a few minutes or brush the teeth with it before starting. Remove any supragingival plaque and calculus. This is most important to the owner because it is what they see; however, it’s the least important to the health of the patient. Begin with the powered (ultrasonic, magnetorestrictive or piezo) scaler. Do not spend more than 10 seconds on a tooth at a time and be sure you are using enough water to cool and irrigate the tooth. Remove the subgingival plaque and calculus with a curette or perio tip. This is the least visible to the owner but the most important to the health of the patient. Plaque bacteria are the cause of periodontal disease, not calculus. The plaque must be removed from any subgingival space. Check your work. Use the air water syringe to rinse the mouth of calculus and blood, then use the air water syringe to dry the teeth. Look for any chalky white residue that remains on the teeth as that’s the calculus that has been missed. Remove what is left with a hand scaler and/or curette. Polish the teeth using fine- or flour-grade paste above and below the gum line. Flare the polishing cup under the gingival sulcus. Use a light touch and spend only five to 10 seconds or less per tooth. Polishing smooths the tooth surface and removes irregularities created by scaling. This decreases the surface area for plaque bacteria to stick to. Once all the calculus and plaque have been removed and the teeth are polished, rinse the tooth surface and sulcus to remove debris and paste. At this point, some like to apply fluoride. Fluoride can decrease sensitivity. Do not use in renal patients because fluoride is excreted through the kidneys and these patients cannot spit it out.

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