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Guidelines for dental treatment in dogs and cats

Ratification Date: 15 Oct 2010

The purpose of this document is to provide guidelines to veterinarians when making diagnoses and when managing periodontal disease in dogs and cats.

Background

To provide optimal health and quality of life, good oral care is necessary. Diseases of the oral cavity, if left untreated, are not just painful, but may also contribute to local or systemic disease.

The requirement for follow-up treatments will be based on the results of the oral examination and the severity of the oral disease, any previous treatments and the degree to which the clinician anticipates improvement from this ‘dental’ procedure. 

Veterinarians need to assess whether their dental equipment and skill level allow them to fully treat the oral pathology present or whether referral to an appropriately trained veterinarian is required.

Definitions

  • Dental prophylaxis (a term synonymous with the colloquial terms ‘dental’ or ‘prophy’) – a procedure including oral assessment under general anaesthesia, diagnosis and formulation of a treatment plan, removal of plaque and calculus above and below the gum line, development of an oral hygiene plan (homecare) and subsequent follow up.
    This procedure is limited to patients without periodontitis as these patients will, by definition, have bony attachment loss around one or more teeth. Treatment of this bone loss will entail more procedures / treatments (as defined below in periodontal surgery, periodontal therapy and oral surgery) than in a prophylactic examination (prophylaxis).
  • Gingivitis – considered to be a reversible inflammation of the gingival tissues without the loss of the tooth’s supporting structures (that may or may not be visible to the eye).
  • Periodontitis – an irreversible destructive process involving the loss of the tooth’s supporting structures (the periodontium), which includes the gingiva, periodontal ligament, cementum and the alveolar bone.
  • Periodontal pocket – a pathological space between supporting structures and the tooth, extending apically from the normal site of the gingival epithelial attachment.
  • Periodontal therapy – the treatment of chronic gingivitis and periodontitis.  Depending on the degree of periodontitis, this may require multiple treatments such as periodontal surgery.
  • Periodontal surgery – the surgical treatment of periodontal disease.
  • Oral surgery – the surgical invasion and manipulation of hard and soft tissues to improve/restore oral health, function and comfort.

Guidelines

1. Oral examination, diagnosis and treatment planning

A full patient history is part of any oral examination. The preliminary physical examination of all body systems is conducted in the consulting room. The extent of this initial examination will depend on the temperament of the animal. The temperament of the animal and the commitment of the owner are assessed at the initial examination as these will influence planning for ´home-care´.

A complete oral examination can only be performed with the animal anaesthetised; excessive calculus deposits may need to be removed to aid in the more accurate measuring of pocket depths with a periodontal probe.

A comprehensive oral examination should be performed and will include periodontal probing; the use of special tests including intra-oral radiographs is highly recommended.

All findings should be recorded on a dental chart which forms part of the animal’s medical record.

Indices including plaque and calculus scores, missing or supernumerary teeth, tooth mobility, bleeding on probing, furcation involvement, gingival recession or hyperplasia should be recorded on the dental chart and are fully detailed in the procedures section of this document.

Based on the findings of these examinations, diagnoses will be made.

Consideration of the diagnoses, patient co-operation and owner commitment will permit the development of an appropriate treatment plan.

2. Equipment, instruments and maintenance
The dental surgical suite
  • As most dental procedures are considered ‘dirty’ and involve general anaesthesia, water and aerosol formation, it is highly recommended that a dedicated space be utilized apart from the sterile surgical theatre.
  • For optimal safety to operators and patients, current Occupational Health and Safety requirements should be complied with including anaesthetic gas scavenging, lighting, operator, assistant and patient protection.
  • It is highly recommended that operator and assistant protection includes the wearing of masks, gloves, eye shields and gowns.  It is also recommended that ear protection and hair-nets be used.
  • Patient protection involves the provision of an impervious surface with adequate drainage on which to conduct the procedure; airway protection involves the use of an adequately inflated cuffed endotracheal tube and pharyngeal packs; and appropriate monitoring including heart rate, blood pressure and temperature. The patient should be adequately protected from hypothermia and hypovolaemia during the entire period of the procedure which may be of variable duration.
Dental base and power equipment
  • To competently, adequately and rapidly clean plaque and calculus from the teeth surfaces it is recommended that some form of power equipment be used. A large choice of such equipment is available, however in essence it consists of:
  • Sonic and/or ultrasonic scalers (to remove plaque, calculus and debris from the teeth surfaces)
  • A slow speed handpiece suitable to accept a prophy-cup used with a polishing paste to remove stain and more plaque.
Hand instruments
  • The minimum set of hand instruments required for dental prophylaxis includes: a dental explorer, a periodontal probe, a variety of scalers and curettes, a dental mirror and a sharpening stone.
Maintenance of power and hand equipment
  • Power equipment should be maintained in good working order according to the manufacturer’s instructions. This includes cleaning and oiling the handpieces after each use and maintenance of the pressure vessel.
  • Hand instruments should be kept in good order including the sharpening of curettes and scalers.
3. Operator and assistant protocols
Veterinarian
  • Performs an initial oral examination of the pet and completes a thorough oral examination and treatment under general anaesthesia
  • Formulates a treatment plan
  • Oversees the dental charting and recording and give written or verbal instructions to the relevant assistant on the implementation of the treatment plan
  • Knows the relevant assistant’s qualifications and capabilities to implement the treatment plan
  • Formulates a homecare plan
  • Liaises with the client directly or via a veterinary nurse regarding the implementation of any homecare plan
  • Recommends to the client that the pet be referred to an appropriately trained veterinarian when the practitioner does not have the skills, knowledge, equipment or facilities to perform a given procedure or treatment
Qualified veterinary nurse
  • Certificate IV qualified veterinary nurses can prepare for these procedures
  • Chart and record the examination findings and clean teeth under the guidance of the veterinarian
  • If appropriately licensed, the veterinary nurse takes and processes radiographs 
  • The veterinary nurse can discuss results of the homecare plan and make follow-up phone calls with clients as instructed by the veterinarian
Veterinary assistants, vet nurse students and enrolled students
  • Can set up for the procedure under the guidance of the veterinarian or a certified veterinary nurse
  • Chart and record the findings and clean teeth under the guidance of the veterinarian
4. Procedures

Dental prophylaxis is performed on a patient with an essentially healthy mouth or with mild gingivitis. The treatment of periodontitis is performed on a patient with existing periodontitis (attachment loss) or with compromised or damaged dentinal structures. Patients with existing periodontitis undergo periodontal therapy not a ‘prophy.’

Stages in dental assessment and treatment

It is not possible to perform a professionally thorough and complete dental examination in the conscious dog or cat. These treatments are both complex and generally uncomfortable or painful and cannot be done in a professional or complete manner in a conscious or sedated animal.

  • Under general anaesthesia, the oral cavity is examined, assessed and graded.  Findings are recorded on a dental chart and a treatment plan is formed. Intra-oral radiographs are taken to further assess the significance and extent of pathology.
  • Scaling using hand and power instruments is performed and findings recorded on the dental chart at this time.
  • Teeth to be retained are polished.
  • Periodontitis and other pathology is treated with the informed consent of the owner using closed or open curettage and/or root planing of subgingival pockets. (A flap would be raised to allow this procedure. Surgical flaps are frequently employed during the treatment of periodontitis to enable access to the subgingival tissues (enabling better visualization of these structures), repositioning of tissues to treat oronasal communications or fistulas etc., removal or re-contouring of bone and as part of the surgical extraction of tooth roots).
  • Extraction of teeth may be indicated for the treatment of:
    • Tooth retention (as in the case of deciduous teeth)
    • Supernumerary teeth
    • Fractured teeth (that are not to be endodontically treated)
    • Periodontally compromised teeth
    • Crowded teeth
    • Endodontically compromised teeth (that are not to be endodontically treated)
  • Perioperative adjunctive therapy (antibiotics, local anaesthesia, analgesia etc) should be administered where indicated.
Peri-operative care
  • Maintain an open and patent airway via intubation until the animal is swallowing and is in sternal recumbency
  • Maintain body temperature and continue adequate intravenous fluid support
  • Maintain and record vital signs until the patient is awake
  • Effective pain management should be provided as required.
Post-operative communication

The client must be fully informed of and agree to the procedures planned and performed to ensure the success of recommended ongoing oral care. This is especially important in cases involving established periodontal disease.

  • The operative procedures along with any existing or potential complications (e.g. bleeding, coughing, dehiscence, infection, neurological signs, halitosis, vomiting, diarrhoea, anorexia and/or signs of pain) should be discussed.
  • Discuss immediate postoperative homecare including medications and their side effects
  • Provide antibiotics and medication for inflammation and pain where indicated
  • Discuss the role of mechanical and/or chemical plaque control in the prevention or control of disease
  • Discuss any recommended changes in diet that are deemed necessary such as a change to soft or premoistened food (short term following periodontal surgery) or to a prescription diet to assist in long term reduction in plaque.
  • Provide individualised oral and written instructions at the time of discharge. 
  • Establish follow-up examinations and ongoing professional care
Homecare plan
  • Effective homecare is vital for the prevention and control of oral disease
  • Assessment of the amount of disease present, the owner’s compliance and the co-operation of the pet to homecare are imperative in the formulation of a homecare plan
  • The homecare plan will include as appropriate the frequency, duration and method of rinsing, brushing, use of sealants, special foods and dental chews
  • This plan may need to be reassessed at follow-up evaluation visits
  • The Veterinary Oral Health Council (VOHC) provides a ‘seal of acceptance’ acknowledging the efficiency of these marked oral products in controlling plaque and/or tartar. The recommendation of VOHC-certified products where appropriate is encouraged.

Date of ratification by the AVA Board: 15 October 2010