The Team | Winter 2013

Winter 2013 | Vol. 10, No. 1

A WealthEnhancing Resource for Independent Veterinary Practices

Protect Your Online Brand Reputation 3 | Food Allergy Breakthroughs 7

Build Revenue with Dental Radiographs 12 | The PU/PD Work-up 18

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From the Desk of Dennis A. Nelson, dvm Fix Your Brand’s Reputation Winter 2013 | Vol. 10 | No. 1

A Wealth-Enhancing Resource for Independent Veterinary Practices Your Veterinarian Pet Care News From ®

A WealthEnhanc ing Res for Inde ource penden Veterina ry Practic t es

10, No. 1 WINTER 2013 | Volume

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SEPARATION

Winter 2013

| Vol. 10,

No. 1

On the Web

IETY ANXdog’s fears Ease your

FOOD ALLERGY REmEDiEs

How to identify food culprits

Protec

t Your Online

Brand

Reputa

tion 3 | Food

Allergy

Breakt

hrough

s7

You found what?

Benefits of dental X-rays Watching your senior pet’s water intake Build

Revenu

e with Dental Radiog

raphs

If you have time to implement just one wealth-enhancing business strategy in 2013, consider monitoring and improving your online reputation.

If you think that influencing customer comments on Twitter, Yelp, Google Maps and other websites is beyond your practice’s web knowledge or budget, you might be pleasantly surprised

by Dr. Jed Schaible’s take on Visit www.psi-inc.net for additional this. Not only is it possible to educational articles. New articles include: build your online reputation, he says, but he also offers • Competing

with Dr. Google strategies for doing it for free— • Lyme

Disease in Dogs or for very low cost.

Customer rankings of your • B eing Proactive About Your business are critical, both Online Brand Reputation to keep existing customers confident in your practice and to bring in new business. Dr. Schaible outlines how to dilute bad reviews and how to encourage your customers to show their appreciation with good reviews. Check out his article on pg. 3.

12 | The PU/PD

Work-u

p 18

The Team is published to complement Pet Quarterly®, an educational resource for your clients. Look for these articles in the current issue of Pet Quarterly: You Found What? (dental X-rays); Never Can Say Goodbye?; Food Allergy Fix; Water Warnings.

A lso in this issue: Visit us on the web at

www.psi-inc.net

• Royal Canin has debuted a new allergy-elimination diet for dogs that shows great promise. In tests, 100 percent of dogs showed significant improvement in skin condition, and most dogs found the diet palatable and digestible. Read more about this breakthrough on pg. 7.

• Make sure you’re not missing dental pathology. Mary Berg tackles the topic on pg. 12 with suggestions on everything from how to get set up with a dental X-ray system to the right angle for taking radiographs to troubleshooting tips for developing X-rays.

The Team is an educational resource published by Purchasing Services Inc., St. Petersburg, Fla. Comments are welcome at info@petquarterly.com

• Is your whole team up to speed on the PU/PD workup? On pg. 18, Dr. Juliet Gladden provides a comprehensive look at diagnosing and managing polyuria and polydipsia with tips for your whole team.

We hope you find this issue helpful for your team and wealthenhancing for your business. Best wishes for a prosperous new year.

Visit us on the web at www.psi-inc.net © Copyright 2012. All rights reserved.

The Team magazine does not make any representations as to opinions or facts as presented. Reproduction of contents in any form is prohibited without prior written permission of the publisher.

Postmaster: Send address changes to: The Team, 2951 34th Street South St. Petersburg, FL 33711

Sincerely,

Dennis A. Nelson, DVM Vice President, Operations Purchasing Services Inc.

www.psi-inc.net | the Team | Winter 2013 1

General Wellness

Seeing Stars Be proactive about your online brand reputation. Star ratings will help you grow your practice … and might even shrink your waistline.

By Jed Schaible, VMD, MBA, CVPM

As a veterinarian, I have received

Protect your brand by diluting the effects of bad customer ratings with lots of five-star reviews.

many handwritten cards, letters, and thank-you notes from clients over the years; I cherish and keep every single one. They warm my heart and remind me of why I am in the veterinary profession. Appreciation is manifested in many ways but usually in the form of cookies, brownies, homemade candy, pies and cakes. Our lunch rooms overfloweth with endless calories that most of us don’t need.

Some expressions of thanks are more useful than others to help build your business reputation. You can hang the cards in your exam room, but you can’t post a double chocolate cake on your wall for all to see. What you really need to boost your business is a good “star rating” at popular ratings sites, such as VetRatingz, Angie’s List, Google Maps and Yelp.

Ask yourself, when was the last time you were given a positive online review as a thank you?

It’s no secret that angry people are far more likely to go the trouble of ranting online with negative reviews than satisfied customers. It is no different in the veterinary world.

You should have a look at where you stand at the most popular ratings sites, because potential clients will choose the practice with the best ratings.

Once you have a look at your ratings and see where you stand, you have to accept that there really is no way to get negative reviews taken down. The solution to the problem is diluting the effects of any bad reviews with lots of five-star reviews. Big brands employ Radian6’s Social Enterprise Solution to accomplish this at a cost of $10,000/ month, but believe it or not, you can help protect your brand using several free services and low-cost strategies. >> www.psi-inc.net | the Team | Winter 2013 3

General Wellness n Step 4 – Find a Distribution Method Go to an online printing store such as UPrinting.com and create business cards for each review site. On the cards, ask your clients to leave positive reviews. Be sure to include the URL and the QR code so that your clients have less of a barrier to leave reviews.

Which practice would you want to take your pet to? As an Associate DVM, where would you want to work?

Driving Dilution Let’s first talk about a low-cost system that I have employed at my practices.

It uses five easy steps to drive your clients to help you dilute your lowstar ratings. n Step 1 – Be Aware First, identify the review sites that contain negative reviews about your practice. If possible, print out the bad ones, read them and then expect to seethe for a while.

You may see horrible reviews from a client you cut a break to or even extended credit; this can be infuriating, but know you are not alone. Be sure to revisit the reviews the next day when you have accepted that they exist. At this point, respond to any negative reviews. If it is possible to leave a comment in response to a negative review, never do so when you are emotional. n Step 2 – Rank and Prioritize Once you have responded to any negative reviews (if possible), rank the review sites from the lowest to the highest average star ratings. For example, if on Yelp your practice has an average star rating of 2.5 and on Google Maps your average star rating is 4.5, Yelp would rank number one and Google Maps would rank number two. This will give you an ordered list that will help you prioritize which sites you will first focus on in step five.

4 Winter 2013 | the Team | www.psi-inc.net

Step 3 – Leverage QR Codes Your goal is to drive clients to the review sites with the lowest star ratings and to make it easy for your clients to leave a review. Identify the URL for each rating site (i.e. www.yelp.com/your-vet-hospital) where a client would go to write a review, then head over to Kaywa (http://qrcode.kaywa.com) and create a mobile-friendly QR code for each site. You can put QR codes in your newsletter, on your receipts, on your website … you are only limited by your creativity. This will allow your clients to scan the code with their phones and leave reviews on their mobile devices at their convenience. n

n Step 5 – Start Improving Your Online Brand Reputation Armed with these cards, start handing them out to your most satisfied clients. Begin with the cards that link to the sites with lowest star rating. Over time, you will dilute your negative ratings and build a better online reputation. Remember, if clients say they are going to bake you cookies, give them cards. This is an excellent way to increase your rankings … and lose some weight!

Monitoring Complaints You may wonder how you can possibly keep track of comments and complaints about your business on social-networking sites and online communities such as Twitter, Facebook and the Crazy Client Blogosphere.

Twitter’s dynamic content stream offers clients a very easy platform that facilitates complaining. It is very easy for a client to include your brand’s “@username” in a negative Tweet, whereas traditional review

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sites require a client to login and create an account. This means that the barrier to complain is practically non-existent. To make matters worse, the nature of Twitter means that one complaint can spark more negativity and spread via re-Tweeting.

So how do you monitor all of Twitter? There is a free tool at Monitter.com that provides you the ability to search all of Twitter for mentions of your brand and your doctors’ names. Typically the best response to a negative Twitter string is to just wait for the hype to die down, but it is good to know about negative reviews in case there is a legitimate customer-service problem at your practice that could pose some liability.

If you are up for a taking the time to create an account and someone in your hospital is familiar with Twitter to provide you with assistance, Tinker.com can integrate with your Facebook and Twitter accounts and will monitor what others are saying about your brand on those platforms.

One of the most powerful tools that can automate the monitoring of your brand reputation (for free) is Google Alerts. Google Alerts will search the blogosphere, review sites— basically the entire Internet—and create email updates of your brand keywords as frequently as you desire.

I prefer alerts “as they happen” so that potential negative comments can be addressed in a timely fashion.

The setting I prefer for the depth of search is “only the best results”— otherwise, non-exact matches may inundate your inbox, depending on the uniqueness of your brand.

With a little effort and some active monitoring of your brand online, you will find that the tables will turn in your favor and that your star ratings will improve greatly. n Jed Schaible, VMD, MBA, CVPM, is an expert in social media marketing, digital publishing, search marketing, practice management and veterinary practice marketing.

Follow Dr. Schaible on Twitter: @JedSchaibleVMD

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www.psi-inc.net | the Team | Winter 2013 5

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Parasites & Dermatology

A New Diet Direction Royal Canin’s Anallergenic diet with hydrolyzed proteins is a significant breakthrough in overcoming canine food allergies.

By Paula Andruss

Would your practice recommend a dog food made from poultry feathers? Many veterinarians might

answer with a reflexive “no”—but they would be missing out on a significant and effective advance in canine foods for allergy-elimination diet trials.

Food allergy, or Adverse Food Reaction (AFR), is a fairly common condition that can cause a variety of serious clinical signs in pets, including intense itching, pain, inflammation and infection of the skin, and gastric problems such as vomiting and diarrhea.

Pets with AFR have a food hypersensitivity, typically an >>

Anallergenic Diet at a Glance Energy Density: 3688 kcal/kg

17.1% ME Protein

44.9% ME

Carbohydrate

38% ME Fat

(ME: Metabolizable energy, or the energy that each nutrient contributes)

www.psi-inc.net | the Team | Winter 2013 7

Parasites & Dermatology uncontrolled immune response to large, ingested proteins, notes Jeff Kellerman, DVM, scientific support manager for pet food manufacturer Royal Canin. To address that issue, Royal Canin is introducing a new advancement in veterinary food allergy elimination diet trials with its Anallergenic diet. Kellerman says Anallergenic is a significant breakthrough for several reasons.

Breaking Down the Problem First, the Anallergenic diet contains proteins that are broken down into amino acids or very short chains, oligopeptides, which reduces or eliminates the possibility of an allergic reaction among even the most severely allergic animals. “One significant strategy in managing these pets is to feed hydrolyzed or cleaved proteins that will not

be ‘recognized’ by the immune system,” he says.

Those small proteins are made possible by another way the diet differs from other elimination trials: its unique protein and nutrient source, poultry feathers.

“Feathers are a source of amino acid,” Kellerman explains. “This same protein source has been used in baby formula, and it has absolutely the same nutrition as other diets. Poultry feathers are also sustainable and do not compete with the human food chain.”

Testing and Taste Quality control of the diet is rigorous. Royal Canin institutes two levels of control, including systematic cleaning of the production line before every run and advanced DNA testing of Anallergenic to ensure that it is free of impurities. “It has undergone extensive testing and is manufactured under strict quality control to ensure safety and efficacy,” Kellerman says.

Along with these nutritional advances, the diet’s acceptance rates are impressive as well, a success Kellerman attributes to the fact that protein-free palatability enhancers are directly mixed with other proprietary nutrients to develop its appealing taste. “The palatability of Anallergenic was tested in dogs in multiple trials and rated as normal to very good for 90 percent of the dogs,” he says.

Breaking the Cost Barrier While some pet owners are reluctant to try therapeutic diets because of their often high price, Kellerman says a little education on the product’s quality and efficacy can go a long way in helping them overcome that hesitation. “Pet owners focus a lot on the cost per bag, but they should look at not just the cost but the efficacy of the diet,” he says. “The job of the veterinarian is to talk about those two issues.” >> 8 Winter 2013 | the Team | www.psi-inc.net

Talking Points for Pet Owners: Nutrients Versus Ingredients To help position the Anallergenic

Taste Tests The palatability of Anallergenic was tested in 22 dogs in multiple trials and rated as normal to very good for 90 percent of the dogs.

diet with clients, Kellerman says it is important to communicate that nutritional support for healthy cells and tissues is based on the assimilation of nutrients, not ingredients. “People typically think about diets in terms of ingredients, like chicken breast, but there’s much more to nutrition to that,” he says.

Kellerman concedes a diet created with feathers may be off-putting to some pet owners, and says that practices will likely

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www.psi-inc.net | the Team | Winter 2013 9

Parasites & Dermatology Instead of comparing diets on a cost-per-pound basis, Kellerman says a more accurate comparison is a “cost-to-feed” basis, which requires more information about the product including energy density, feeding guidelines, digestibility and the quality of the nutrients.

In addition, he says, it’s not uncommon for over-thecounter diets to be tainted with multiple protein sources not listed in the ingredient list, a problem because food elimination diets must be free of impurities and unknown elements in order to diagnose food allergies and manage them long-term, which Allergenic is approved to do. “But [pet owners] don’t see that,” he says. “What they do see is that the bag is $10 cheaper on a weight basis.”

Of course, if a diet doesn’t work, those per-bag savings disappear quickly as pet owners are left to try other diets until they find one that is successful.

To that end, Kellerman urges practices to ask clients to consider starting with a diet that has undergone rigorous quality control measures and testing to achieve the best possible results.

“They may save on one bag but then have to undergo several trials,” he says. “It’s better for everyone to say ‘Let’s just make the first choice be the best diet that we can.’” n

Trial Results Scientific trials of the Royal Canin diet show promise across a large sector of dogs. In a multi-center trial at six veterinary practices in dogs suffering from Adverse Food Reaction, 100 percent of dogs showed significant improvement in skin condition, and 37.5 percent of dogs’ skin conditions resolved completely. In addition, the survey found that Anallergenic was palatable and digestible; the average digestibility score was 3.9 out of an optimal 4, making it very promising in terms of patient compliance.

The Team Approach The Team Approach Due to the new technology behind the Anallergenic diet and its protein source, Jeff Kellerman, DVM, scientific support manager for Royal Canin, says a consistent approach is critical to introducing the new diet to clients and gaining compliance for treating their pets’ food allergies. Here are some ways your entire team can get involved:

Veterinarians Provide an initial introduction to the diet. Explain the nutrition behind it with an emphasis on the nutrients-versus-ingredients message. Train the rest of the staff to make sure there is a consistent approach.

Technicians Be available for follow-up questions from pet owners. Deliver a consistent message about the diet and its nutrition. Reinforce that it is a viable option for pets going forward.

Receptionists Make sure brochures, signage and other marketing materials 10 Winter 2013 | the Team | www.psi-inc.net

are visible in waiting/reception area to help facilitate discussions.

Practice Managers Identify candidates for the diet by flagging new patients coming in with suspected allergies, chronic dermatological cases and patients who did not succeed when going through other trials.

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Dental Health

X-ray Vision Make sure you catch dental pathology—and build practice revenue at the same time—with these easy steps for dental radiographs.

By Mary L. Berg, BS, RVT, RLATG, VTS (Dentistry)

Are you missing dental pathology during oral examinations? Dental X-rays

Positioning for mandibular molars

Positioning for mandibular incisors

Positioning for maxillary 4th premolars

Positioning for mandibular canines

will take your practice to the next level by giving you the ability to diagnose pathology that is not visible on the crown of the tooth. Dental radiographs are an essential part of every oral exam, since about 42 percent of dental pathology is found subgingivally.

X-rays can confirm suspected pathology, help demonstrate the pathology to the client and increase your clinic’s revenue.

In an ideal scenario, a full survey set of radiographs would be carried out on all patients annually using multiple views to ensure that each tooth is radiographed.

Most clinics do not take full survey radiographs and thereby miss the chance to find pathology that may not be clinically evident.

Radiographs should be taken when these problems are present: periodontal disease, endodontic disease, tooth resorption, draining tracts, trauma, oral masses, dental abnormalities and pre-, intra- and post-surgical evaluations.

Paying for Itself

Positioning for maxillary canine

12 Winter 2013 | the Team | www.psi-inc.net

Positioning for mandibular molar

The expense of a dental X-ray system can pay for itself in a very short time. To take your dental program to the next level, take a full series of X-rays on each patient at the time of a routine dental cleaning. You don’t need to set the price extremely high for this additional service. The additional pathology you discover from these X-rays will help pay

for the system.

I don’t recommend giving pet owners the option of deciding whether their pets should have X-rays. Instead, consider it standard practice, similar to requiring blood work prior to each surgical procedure. If the owners understand the need for the X-rays, they rarely have a problem. Explain that their pet can’t tell you where it hurts, but the X-rays can.

Dental radiograph units are relatively inexpensive. They are low maintenance and the film and chemicals are inexpensive. You can purchase used units very reasonably from dental supply companies.

Medical radiograph machines can be used but are inconvenient, and they often do not show the detail necessary to make a definitive diagnosis.

Unit Overview Dental radiograph units allow for accurate positioning without having to move the patient. They are compact, maneuverable, have limited settings, and the tubehead ensures less radiation scatter than medical x-ray machines. The settings for kVp (kilovolt peak) and mA (milliamp) are preset, leaving exposure time as the only adjustable setting (Photo 1).

Dental films come in four sizes; the most common sizes are 2 and 4.

The film has a bubble on the upper-

1

left corner to help with orientation.

This bubble should always be placed toward the X-ray beam and toward the caudal aspect of the oral cavity. The film has multiple layers; these include the white plastic outer layer, a silver lead layer, a paper layer and the film (Photo 2).

DIY Developing Chairside darkrooms are inexpensive, provide rapid results and are easy to use (Photo 3). You could buy an automatic processor that is dental X-ray specific, but these can be expensive.

Luckily, hand developing in a chairside darkroom is a very simple process. You’ll need: n Holder clips (to hold the film as you develop it to avoid fingerprints) n Light boxes with a magnifying lens (to read the films) n Fresh developer and fixer solutions Follow these steps to develop the X-ray film: 1. Place the film inside the chairside developer; put the red cover in place.

2. Place your hands through the hand holes.

3. Open film packet; remove film; attach film clip.

4. Place film in water for 5 seconds. >>

2

3

The Team Approach Working together, your whole team can help incorporate dental radiography into your practice.

Veterinarians Become confident in diagnosing oral pathology from dental X-rays. Attend continuing education courses to help understand normal versus abnormal findings on dental X-rays.

Technicians Become proficient and efficient at taking diagnostic dental X-rays.

Practice is the best way to learn to take quality dental X-rays.

Receptionists Explain the importance of dental X-rays to clients. Help them understand that the X-rays can find problems that may not be visible in their pet’s mouth.

Practice Managers Create an environment that ensures that your dental X-ray equipment, training and continuing education allow for the practice of quality medicine.

www.psi-inc.net | the Team | Winter 2013 13

Troubleshooting Tips

Solve common problems encountered in dental radiography.

Table 1: Light Radiographs with Poor Contrast Problem

Cause

Correction

Underdeveloped

• Old or diluted chemicals • Too short of developing time • Overfixation • Low chemical temperature

• Replace • Lengthen developing time • Shorten fixation time • Adjust temperature

Underexposed

• Film position backwards • Insufficient exposure time • Low mA or kVp • Excessive distance film to tube • Hand switch not depressed properly

• Correct position • Increase time • Adjust settings • Adjust settings or distance • Engage switch entire time

Table 2: Dark Radiographs with Poor Contrast Problem

Cause

Correction

Overdevelopment

• High temperature • Developing too long • Concentrated developer

• Adjust temperature • Adjust time • Change developer

Light Exposure

• Darkroom leaks or improper safety lights

• Evaluate integrity of darkroom and safelight

Radiation Exposure

• Unexposed film too close to beam • Excessive mA, kVp or time

• Relocate unexposed film • Adjust settings

Overexposure

• X-ray tube too close to subject

• Increase distance from subject to tube

Table 3: Spots, Stains or Marks Problem

Cause

Correction

Dark stains, lines or smudges

• P re-developing contamination with developer

• Careful technique

White spots

• Fixer contamination prior to processing • Film in contact with tank or other film

• Careful technique • Process separately

Uneven development

• Air bubbles • Depleted developer or fixer

• Agitate film during processing • Change chemicals

Yellow or brown stains

• Inadequate fixation • Inadequate washing • Contaminated solutions

• Adjust fixation time • Fresh water and increase time • Change chemicals

Streaks

• Inadequate washing • Contaminated water • Contaminated hangers • Uneven concentration of developer

• Increase time • Fresh water • Clean hangers • Agitate film in developer

Black spider web lines, • Static electricity generated by lighting streaks opening the film packet too fast

14 Winter 2013 | the Team | www.psi-inc.net

• Open film packet slowly

5. P lace in developer for 30 seconds.

6. Wash in water for 30 seconds.

7. P lace in fixer for 10 to 15 seconds, reviewing film in 10 seconds.

8. I f film is diagnostic, place back in fixer for 10 minutes, then rinse thoroughly in water 60 to 90 minutes.

Once developed, your dental radiographs will need to be labeled.

Using radio opaque markers or permanent markers may interfere with the radiographs, because they are so small. Instead, buy cardboard or plastic holders with space to label the radiographs. Place these holders in the patient file or in a specific storage cabinet. You can also use envelopes or slide holders.

I have found that plastic businesscard holders that can be placed in a three-ring binder are very useful for storing film sizes 0, 1 and 2. A similar holder designed for baseball cards works well for number 4 films.

Digital Advantage There are many advantages to purchasing a digital dental X-ray unit. These units are becoming much more common. Digital X-ray units produce an image within seconds, thus reducing anesthesia time. Once the images are on the screen, they can be manipulated.

You can zoom in on a specific area, change colors or reverse contrast to help identify structures. A set of X-rays can be printed to send home with the owner or to a dental specialist for consultation. Digital dental X-rays also reduce the cost of consumable supplies such as film and chemicals and the need to have storage places for the films. Even if you go digital, keep some film and chemicals in your practice in case of a computer failure.

There are many digital sensors available in both DR (digital radiology) and CR (computed radiology) units. DR units generate an image directly to the computer

Dental Health screen, while CR units require a film-like sensor to run through a reader unit prior to appearing on the computer screen. DR sensors are most often the size of a number 2 film. The most important things to look for when choosing your digital dental X-ray system are image quality and ease of use of the software. Some CR units allow for multiple film sizes, which can be a convenience for some practices.

axillary canine (cats): 60 M degrees n Maxillary molars and premolars (cats): 30 degrees n Maxillary canines: 60 degrees n Mandibular incisors: 4 degrees n Mandibular molars: 90 degrees (See photos on pg. 12.) n

If the beam is not perpendicular to the bisecting angle, the view of the tooth will be distorted. An

angle that is too low will cause elongation, while one that is too high will cause foreshortening.

(See illustration on pg. 16.)

Certain teeth require advanced X-ray techniques. For example, the maxillary P4 is a three-rooted tooth. If you use the bisecting angle technique, the palatal root will be superimposed behind the mesiobuccal root. Using the SLOB (Same Lingual, Opposite >>

Safety First As when working with any type of radiation, it is important to observe radiation safety guidelines and keep your radiation exposure to a minimum. If possible, step outside of the room; if not, stay at least six feet away from the unit and out of the line of the beam. Always wear a film badge to measure your exposure and use a positioning device to help keep the film in place (a gauze 4x4 works very well and is disposal and inexpensive).

For a full radiographic survey, include radiographs of the anterior maxilla, anterior mandible, posterior maxilla (left and right) and posterior mandible (left and right). You may need to take additional radiographs to view specific teeth or for larger animals.

Working the Angles When learning proper positioning, it helps to place the animal in sternal recumbency with the maxilla parallel to the floor for taking X-rays of the maxillary arches. For the mandible, place the animal in dorsal recumbency with the mandible parallel to the floor.

You may need to use towels help position the animal’s head.

All dental X-ray generators have numbers that indicate angles. These angles can help achieve proper positioning: n Maxillary incisors: 45 degrees n Maxillary molars and premolars (dogs): 60 degrees n Maxillary canine (dogs): 70 degrees www.psi-inc.net | the Team | Winter 2013 15

Dental Health

Radiograph Angles

Normal Projection

Foreshortened Projection

Elongated Projection

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Buccal) rule will result in viewing all three roots. The tubehead is shifted slightly rostal or caudal to visualize all three roots. If the tube head is moved caudally, the palatal or lingual root will be most caudal on the radiograph. If the tube head is moved rostrally, the lingual root will be the most rostral root on the radiograph (see diagrams on pg. 17).

In cats, radiographs of the maxillary premolars and molars utilizing the bisecting angle technique results in superimposition of the zygomatic arch or the apex of the root. To eliminate this superimposition, you can use an extraoral view of the feline maxillary premolars and molar. You may also intentionally elongate the view to eliminate the superimposition.

To view the radiographs, orient the film on the viewbox so that the raised dot projects toward you. The resultant image appears as if you are looking from the outside of the mouth inward.

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The goal of dental radiology is to take diagnostic radiographs. It is important to have the correct teeth in your radiographs as well as the entire tooth with a minimum of 2 mm of bone around the roots.

Because contrast is vital, avoid overexposing or underexposing the film. Films that are underexposed will have a white appearance, making the teeth and bones seem to coalesce so it is difficult to tell them apart. Overexposure of the film will give a dark film, lacking contrast and with a ghost-like appearance. Cervical burnout or blackening of the neck of the tooth can also happen in overexposure.

Technical errors can occur at any stage in dental radiology. This can be due to film placement, patient positioning, angle of the X-ray beam, incorrect exposure, processing, storage or any combinations of each. (see tables on pg. 14).

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But with the correct attention paid to your technique, your team can take your dental practice to the next level. Increase your dental revenue and improve your patients’ health by finding hidden pathology. n Mary L. Berg specializes in dentistry at Gentle Care Animal Hospital in Lawrence, Kansas.

References: • Mulligan TW, Aller MS, Williams CA. Atlas of Canine & Feline Dental Radiography, Veterinary Learning Systems, 1998. • Holmstrom SE, Frost P, Gammon RL. Veterinary Dental Techniques for the Small Animal Practitioner. W.B. Saunders Company, 1992 • Holmstrom SE. Veterinary Dentistry for the Technician and Office Staff, W.B. Saunders Company, 2000.

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Senior Wellness

Mind Your PU/PDs Polyuria and polydipsia are often overlooked indicators of disease in senior pets. Get your whole team involved in the PU/PD work-up.

By Juliet Gladden, DVM

The good news is that pets are living longer. As this trend

continues, the veterinary community will be facing increasing numbers of geriatric patients. Early detection and management of a number of chronic diseases will be key to longevity for many of these senior patients.

The development of polyuria and polydipsia (PU/PD) is a frequent but often overlooked indicator of several important diseases of senior pets. Here’s an overview of the PU/ PD work-up with tips for your whole practice team.

Imbalance Indicators Polyuria and polydipsia are indicators of total body water imbalance. Polydipsia is characterized by excessive water consumption. Polydipsia in dogs and cats is defined as water consumption greater than 100 ml/ kg/day. Psychogenic polydipsia is uncommon in dogs and has not been reported in cats.

Polydipsia in senior patients is typically due to polyuria, an excessive production of urine that can result from physiologic, compensatory and pathologic etiologies. Polyuria is defined as urine production greater than 45-50ml/kg/day in dogs and cats. It is important to distinguish excess (large volume) urination (polyuria) from frequent (small volume) urination (pollakiuria), as these clinical entities often represent very different disease processes. Pollakiuria is typically noted in patients with lower urinary tract disease and is often a sign of urinary bladder wall irritation or inflammation. Polyuria and 18 Winter 2013 | the Team | www.psi-inc.net

compensatory polydipsia in senior patients is often an indicator of systemic disease.

The body’s fluid balance is determined by special receptors in the body that monitor blood concentration (osmoreceptors), blood pressure (high pressure baroreceptors) and blood volume (low pressure baroreceptors).

Thirst levels, water balance and urine production are the result of the important cross-talk between specific hormones, neural activity and the kidneys in response to these receptors. Key hormones, including vasopressin (anti-diuretic hormone), angiotensin II and aldosterone, work in concert to establish an appropriate water and electrolyte balance in the body. Kidneys need to maintain a high concentration of solutes (sodium, urea) in the medullary region in order for hormones such as vasopressin to function properly.

Diseases that involve the kidneys and major endocrine systems can

disrupt the delicate balancing act required to maintain appropriate body fluid levels, resulting in polyuria and polydipsia. Diseases that increase plasma osmolality, alter blood flow, cause medullary solute washout, damage the kidneys or interfere with hormones such as vasopressin will cause polyuria and polydipsia.

Many senior patients have polyuria with compensatory polydipsia. Common causes of polyuria in geriatric cats are renal disease, diabetes mellitus and hyperthyroidism. In geriatric dogs, major causes include renal disease, diabetes mellitus and hyperadrenocorticism. Several medications commonly administered to senior patients, including corticosteroids, diuretics and anticonvulsants, are also known to cause polyuria and polydipsia.

Diabetes insipidus and a number of other diseases also cause polyuria and polydipsia in geriatric pets.

First Contact The diagnostic evaluation of PU/ PD patients starts with an astute front-office staff member who is able to recognize the problem when pet owners first call the clinic.

If pet owners ask questions about how to correct behaviors such as urinating outside the litterbox or enquire about methods to remove urine from household surfaces or pet bedding, prompt them to schedule an appointment with a veterinarian.

Many senior pet owners assume that changes in water consumption and urination habits are “normal” signs of aging and are unaware that these are often the first signs of serious systemic diseases. Give pet owners guidelines for appropriate

pet water consumption (a quick estimate is that a 10-pound pet should consume about 1 cup of water a day) to help them better gauge if their pets may have a problem. Water consumption may be higher in areas with warmer climates, in febrile patients, in pets fed salty treats or food scraps and in hyperactive patients.

Encourage pet owners to make early morning appointments for problems suspected to be related to polyuria and polydipsia, or instruct them on how to properly collect a urine sample from their pet first thing in the morning. Early morning urine sample collection is ideal when evaluating a patient’s urine specific gravity, as samples

tend to be more concentrated earlier in the day. If clients are unable to schedule early morning appointments, let them know that urine samples can be refrigerated for six to eight hours.

To increase owner compliance, have urine-collection kits available with clear instructions and the necessary equipment. Having premade urine collection kits readily available also minimizes reliance on owner-improvised containers that can be contaminated. You can send urine-collection kits home with senior-pet owners for routine screening purposes as well.

To promote the benefits of senior wellness health diagnostic screening tests, send these kits to owners of >>

PU/PD: The Team Approach A clinic-wide awareness to identifying and managing polyuria and polydipsia in senior pets will lead to the rewarding, long-term, successful management of many common chronic diseases.

Client Care Coordinators

Technicians

Generate reminders for patients due for senior wellness exams.

Call senior-pet owners prior to their visits and encourage them to collect urine from their pets (this step increases pet-owner compliance). Recognize key words or phrases that pet owners may use when calling in with senior-pet questions about polyuria and polydipsia. Remind clients who arrive for seniorpet wellness exams that the veterinarian will need to collect a urine sample during the visit. To help ensure that adequate urine samples can be collected, encourage owners to wait to walk their pets outside until after the visit.

To help identify potential PU/PD patients, include questions about pets’ drinking and urination habits when obtaining thorough patient histories. Observe senior patients that are hospitalized or boarding for excessive drinking and/or urination. These PU/PD signs are important indicators of disease that are often overlooked by pet owners at home. To increase client compliance with athome urine monitoring, review quick tips with pet owners about how to properly collect urine from pets. Distribute pre-made urine collection kits with simple printed instructions and the necessary supplies for appropriate home collection.

Practice Managers

Veterinarians

Promote senior-wellness programs that include client education and senior diagnostic screening panels. This should be part of an ongoing effort to help improve the care of senior pets and ensure patient longevity. To increase staff awareness and allow them to better educate clients on key issues, encourage veterinarian and technician CE programs within the hospital, discuss the benefits of senior wellness screening and review the diagnosis/management of common geriatric diseases.

Consider adding ultrasound to your practice to expand your diagnostic capabilities for senior pets.

For a simple and quick way to screen for several key etiologies of PU/PD, have pet owners collect a urine sample at home first thing in the morning prior to their annual senior wellness exams.

Recommend yearly senior wellness diagnostic testing that includes a CBC, chemistry panel and urinalysis on all pets over 8 years of age. This is a good way to screen for many of the diseases that can cause PU/PD. Remember serial urine specific gravity monitoring may be required to establish a diagnosis in many senior pets with polyuria and polydipsia. Explain to clients the rationale behind repeat urine assessments to increase compliance. www.psi-inc.net | the Team | Winter 2013 19

Senior Wellness senior pets along with annual exam reminders and information on senior health issues.

Get the Facts Technicians are instrumental in guiding owners during history collection to determine if potential changes in water consumption and urination have occurred. Although it’s important to ascertain if pets have had any coughing, sneezing, vomiting or diarrhea, additional directed questions about urinary tract issues and a pet’s drinking habits should also be included in the history.

Medications including corticosteroids (ex. prednisone), diuretics (ex. furosemide) and anticonvulsants (ex. phenobarbital) often cause polyuria and polydipsia.

Any recently administered medications should be well documented in the medical record and the potential side effects of these medications reviewed with owners at discharge.

If owners of senior pets present with a urine sample obtained at home, it is important for technicians to record information on where and how the sample was collected and details on how it was stored prior to arrival at the clinic. This information is vital to the final urinalysis interpretation and may dictate if additional urine samples will need to be collected during the pet’s exam.

Evaluation Options Nervous pets and senior pets with polyuria are prone to urinary accidents and may urinate before or during their exam. Voided urine samples can be collected from clean surfaces with a sterile syringe and evaluated for urine specific gravity and the presence of glucose. Note, however, that these voided urine samples are frequently contaminated with cells and bacteria from the distal urethra and the environment and are not appropriate for a sediment exam.

Ideally, urine should be obtained 20 Winter 2013 | the Team | www.psi-inc.net

via cystocentesis when performing a complete urinalysis with sediment exam and urine culture. Discuss with pet owners in advance the logistics and benefits of obtaining urine samples via cystocentesis. Explain to anxious pet owners that samples are collected in a gentle, pain-free

manner. Highlight the merits of evaluating urine collected directly from the bladder to help alleviate pet owners’ concerns and increase diagnostic testing compliance.

Recently, diagnostic ultrasound has become more affordable, and many clinics may now have access

TABLE 1: Diagnostic Evaluation of Lower Urinary Tract Disease Category 1*: USG >1.025 (serial), no urine glucose n Urinalysis-urine

specific gravity, urine dipstick, sediment exam (cystocentesis sample) n Urine culture (cystocentesis sample) n Urinary tract imaging: abdominal radiographs, ultrasound, cystoscopy n Neurologic Exam n Behavioral Assessment * See Diagram 1

TABLE 2: Diagnostic Evaluation of Polyuria Category 2*: USG >1.025 (serial), glycosuria n Urinalysis-urine

specific gravity, urine dipstick, sediment exam (cystocentesis sample) n Urine culture (cystocentesis sample) n Serum/urine ketone levels (dipstick or beta-hydroxybutyrate meter) n Serial glucose assessments (fasted samples) n Fructosamine level n CBC, chemistry (including electrolytes) n Abdominal imaging: radiographs, ultrasound n Insulin Growth Factor I (IGF-I) (cats) n Consider concurrent endocrine testing (see below)

Category 3*: USG <1.025 (serial) n Urinalysis-urine

specific gravity, urine dipstick, sediment exam (cystocentesis sample) n Urine culture (cystocentesis sample) +/- urine protein:creatinine assay n CBC, chemistry (including electrolytes) n Ionized calcium n Blood pressure (serial ideal) n Abdominal imaging: radiographs, ultrasound n ACTH Stimulation, Dexamethasone Suppression Tests (dogs, rarely cats) n Thyroid panel (cats, dogs on thyroid supplements) n Consider CT/MRI imaging of brain n Consider synthetic ADH trial (when all other differentials are excluded) * See Diagram 1

Diagram 1: Urinalysis-based Diagnostic Evaluation of PU/PD

to in-house ultrasound equipment.

Ultrasound-guided cystocentesis helps minimize iatrogenic injury from sample collection and also provides important information about the lower urinary tract.

With some practice, veterinarians can learn to use ultrasound to assess the urinary bladder for the presence of bladder stones and wall abnormalities. These changes often can be quickly determined during ultrasound-guided cystocentesis, providing the veterinarian with valuable additional diagnostic information.

Despite recent advancements in veterinary medicine, a simple urinalysis still remains one of the most diagnostically useful laboratory tests in patients with polyuria and polydipsia. A urine specific gravity and urine dipstick screen provide a wealth of information about the underlying etiology of polyuria and polydipsia in many senior pets. >>

Presumed Polyuria and Polydipsia

USG>1.025 (serial)

Glucose Negative

USG<1.025 (serial)

Glucose Positive Polyuria (Catergory 3)

Lower Urinary Tract Disease Suspected (Category 1)

Diabetes Mellitus Suspected (Category 2)

Hypothyroidism is the most over-diagnosed hormonal disorder in dogs.

>>

Senior Wellness

Did You Know? n Urine

specific gravity is a measurement of the density of urine compared to the density of pure water expressed as a ratio and therefore has no units.

n Hypersthenuria

is the term used to describe urine with a high specific gravity that is therefore considered concentrated.

(USG >1.030-1.040 in dogs, >1.0351.060 in cats)

n Isosthenuria

is the term used to describe urine with a specific gravity equal to that of plasma. Isosthenuria is common in patients with renal disease. (USG 1.008-1.012 rangeâ&#x20AC;&#x201D;can vary with hydration status)

n Hyposthenuria

is the term used to describe urine that is dilute and therefore has a specific gravity less than that of plasma. (USG <1.008)

n Urine

osmolality can be roughly estimated from urine specific gravity by multiplying the last two digits of the USG by 36. (Ex. USG=1.010, 10 X 36=360 mOsm/kg).

n Effective

plasma osmolality can be roughly estimated by doubling the plasma sodium levels. (Ex. Na=140 mmol/L, 2 X 140= 280 mOsm/kg). Normal values range from 290-310 mOsm/kg in dogs and 290-330 mOsm/kg in cats.

n Patients

with polydipsia and compensatory polyuria will typically have a normal to decreased plasma osmolality and a decreased urine specific gravity/ osmolality.

n Patients

with polyuria and compensatory polydipsia will typically have a normal to increased plasma osmolality and a variable urine specific gravity/osmolality.

22 Winter 2013 | the Team | www.psi-inc.net

These two tests can rapidly provide veterinarians with information that is essential for prioritizing further diagnostic evaluation (Diagram 1, Tables 1 and 2).

Coping Strategies Urinary incontinence and inappropriate urination associated with polyuria in senior pets commonly contribute to pet owner dissatisfaction and frustration.

Educating clients on how to address and manage polyuria in their senior pets will help maintain a healthy veterinarian-client-pet bond.

You can prescribe medications that help manage urinary incontinence, and you can also discuss behavioral and environmental modification options for pets with severe polyuria and polydipsiaâ&#x20AC;&#x201D;this gives senior pet owners strategies to cope with changes in their petâ&#x20AC;&#x2122;s elimination habits.

Many of the causes of polyuria and polydipsia in senior pets can be successfully managed. The successful management of polyuria and polydipsia depends on correctly identifying the underlying etiology.

Early detection is key to initiating treatments that may not only slow the progression of disease but also potentially prevent the development of serious complications.

Chronic kidney disease in dogs and cats can be managed with diet changes and fluid support, ultimately slowing the progression of this common disease. Serial monitoring of urine samples in senior pets with diabetes mellitus and chronic kidney disease may detect secondary bacterial infections before pyelonephritis and a potential acute on chronic renal failure episode develop. Many common endocrine diseases such as hyperthyroidism and hyperadrenocorticism can be effectively managed with medications capable of reversing a number of co-morbid conditions in these patients.

Diseases such as diabetes mellitus in cats may be effectively

DIY Kits

What to include in a Urine Collection Kit n Simple

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(for cats) managed with diet alone if detected prior to the onset of insulin dependence. Diagnosing chronic diseases before a crisis develops helps to avoid the emotional distress pet owners experience when their senior pet acutely decompensates. Early detection, appropriate at-home monitoring and treatment of insulin-dependent diabetes mellitus in dogs and cats may circumvent the development of life-threatening ketoacidosis.

Pet owners who are educated about common early warning signs are more likely to return to their veterinarian before serious complications arise.

The early diagnosis and management of chronic diseases that are associated with polyuria and polydipsia in senior pets ensures that your patients will live longer, healthier lives. n Dr. Juliet Gladden is an emergency and critical care resident at BluePearl Veterinary Partners in Tampa, Fla.

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Quiz TEST YOUR KNOWLEDGE Quiz questions are based on artic les in the current is sues of The Team an d Pet Quarterl ÂŽ y

1 What is not a method of helping dogs with separation anxiety?

A. Videotaping them home alone B. Teaching calm behavior with people present C. Associating departures with something good D. Using desensitization and counter-conditioning 2 Polydipsia in dogs and cat s is defined as water consumption greater tha n ____ ml/kg/day.

A. 75 C. 100 B. 85 D. 120 3 What term is used to descr ibe urine with a specific gravity equal to that of pla sma?

A. Isosthenuria B. Hypersthenuria C. Hyposthenuria D. Urine osmolality 4 What percentage of denta l pathology is found subgingivally?

A. 15 percent C. 33 percent B. 27 percent D. 42 percent 5 When troubleshooting de ntal radiographs, what is a possible cause of lig ht radiographs with poor contrast?

A. Overfixation B. Excessive mA C. High temperature D. Developing too long

6 When taking dental radiog raphs, what is the correct angle for mandibu lar molars?

A. 45 degrees C. 70 deg rees B. 60 degrees D. 90 deg rees 7 What is the key ingredien t in a breakthrough new diet for food allergies?

A. Fish oil B. Poultry feathers C. Marigold extract D. Ash 8 True or false: Hydrolyzed proteins are not recognized by an allergic dogâ&#x20AC;&#x2122;s immune system.

A. True B. False

9 When monitoring your bra nd what free service has a po reputation online, werful tool for reviewing complaints about your bu siness on a timely basis?

A. Facebook B. Yelp C. Google Alerts D. Twitter 10 When encouraging clie nts to write positive review s about your business, wh at key piece of informati on should be printed on you r business cards?

A. Source Code and busine ss homepage B. QR Code and the review site page URL you are targeting for reviews C. QVC Code and Superpag es listing website D. Bar Code and Yelp review page

B.

, 5-A, 6-D, 7-B, 8-A, 9-C, 10-

Answers: 1-D, 2-C, 3-A, 4-D www.psi-inc.net | the Team | Winter 2013 25

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