Patricia M. Dominguez
BS, LVT, VTS (Dentistry) | Gotham Veterinary Center | New York, NY
Patricia received her bachelor’s degree in biology and Spanish literature from Syracuse University in 1999 and was subsequently licensed in veterinary technology at SUNY Delhi. In 2003, she became the primary dental technician at Shaker Veterinary Hospital in Albany, New York, which, through improvements to its dental program and extensive client and community education, earned the Hill’s National Pet Dental Health Month Award 2 years in a row. One of the first to become a credentialed veterinary dental technician specialist through the Academy of Veterinary Dental Technicians, Patricia is the president elect of the academy and an adjunct professor at Westchester Community College.Read Articles Written by Patricia M. Dominguez
Congratulations! You have decided to improve the dental services your practice offers to pet owners by becoming an advocate for pets’ oral health. This can be a daunting task, but by bringing awareness to disease that is often forgotten because it is masked by many animals, you will be helping your patients live healthier, longer lives.
Agree on the Message
I have been fortunate enough to travel to many general practices in the United States as well as in other countries. One constant factor I see in practices that successfully improve their patients’ oral health is that the entire team has decided to make dentistry important. When everyone is on the same page, owners receive a unified message about dental health throughout their entire experience in the practice. However, if dentistry is important to only a few staff members, owners often receive mixed messages about their pets’ oral health, which inadvertently sabotages any efforts to grow dental services.
The best way to ensure that the entire practice is promoting the same message is to have a clear understanding among all staff members about what the message is. This can be accomplished at regular departmental and staff meetings. The main points of oral health advocacy should be agreed on by the entire staff. Every staff member should feel comfortable explaining the practice’s views on oral care and what treatment options it can provide. BOX 1 lists several organizations with resources that practices can use to help create a high-quality dental program or assess their current dental services.
To help reinforce these messages with clients, the practice should create a take-home oral health information packet that includes the following:
- A description of what happens when a patient is being considered for a dental procedure—the preanesthetic examination, preanesthetic bloodwork, a complete dental evaluation, and discussion of a treatment plan
- A complete list of the dental services the hospital provides, including what the team does during each dental procedure
- Authorization of consent if the client cannot be reached during the procedure
- Information on payment options in case full payment is not possible
- A guide to oral care products and how to keep the pet’s teeth clean at home after a dental procedure
You can start changing owner—and staff—perception of dental services simply by using the correct terms. Most dental procedures are not “just a dental” or “just a prophy.” A true dental prophylaxis is performed to prevent periodontal disease. In most patients, dental procedures to restore oral health involve treating periodontal disease. Be sure to convey this to owners during office visits and dental consultations.
Designate a Dental Area
Most animal care facilities are busy and noisy, which can make it difficult to discuss important matters with owners. This is especially true when it comes to involved oral treatment plans. To minimize distractions, designate an area in the practice that can be used as a “dental room” or a “dental corner.” This area should be quiet and have good lighting so that you can see everything in the patient’s mouth before talking to clients about your observations, assessments, and recommendations for a treatment plan.
If a designated room is not possible, a relatively private, quiet area is the next best thing. This can be a regular examination room, the dental suite, or a separate area of the waiting room. Try to avoid explaining procedure details, treatment plans, and estimates in public areas. Dental procedures tend to be higher-priced services and should be discussed privately with owners. Most owners do not want their pets to live with infection or pain; however, they are sometimes limited by their financial situation.
Choose Your Teaching Tools
A dental area also gives you a place to keep educational tools within easy reach to show to pet owners. As your dental services grow, it may make more sense to keep these items in each examination room to display dental awareness throughout the practice. Veterinary product manufacturers and distributor representatives may be able to help you find some of these educational tools.
Plastic skull models: These are available with or without gum tissue, removable teeth, and pathology. Personally, I find the clear, soft models with removable teeth enlightening. Owners are often shocked to see how large tooth roots are and that many teeth have multiple roots.
Bone skull models: These are very useful when showing owners how close tooth root structures are to the sinuses and eye orbits.
Dental charts/posters: These charts can show owners how periodontal disease can progress and lead to other issues affecting the heart, lungs, liver, and kidneys.
Photo album of oral pathology: This can be a handheld album or a digital one. The important thing is to highlight common conditions so that you can refer to photographs when explaining a certain condition.
Photo guide to a complete dental procedure: This type of guide is comforting for owners who have never had a dental procedure explained before. It should be set up as a step-by-step album that takes owners through the preanesthetic visit all the way to the dental discharge. This album can also be handheld or digital.
Promote Your Practice
Showcasing the importance of dental care in your practice should not just stay within the hospital walls. Social media can also be a powerful tool for promoting oral health. Social media accounts can be maintained by a knowledgeable, dedicated team member or outsourced to a veterinary-specific company geared toward increasing your online presence. You can also use your practice’s website, newsletter, and e-mail database to distribute information about dental awareness.
Reaching out to the community can include promoting educational events at local pet stores, adoption centers, or training classes. Another way to bring current and potential clients to your practice is to host an open house. This will allow you to showcase your facility, staff, and services. You can focus on a particular topic, such as oral health, or open it up to a variety of topics. Such events can help you develop a more personal relationship with owners and educate them on issues affecting their pets’ health.
To properly communicate canine and feline dental pathology to owners in the examination room, you must be completely familiar with evaluating the teeth and skull structure of all the breeds that come into your practice. When you can flip the lip of every patient you see and show the owner exactly what you observe, it helps the owner understand the need for treatment if an abnormality is noted during a physical examination.
Communicating During the Initial Examination
By incorporating a thorough oral examination into regular physical examinations, the veterinary staff can begin to teach a new generation of pet owners to recognize oral care as part of good overall care. Unfortunately, oral health has typically been overlooked in the past. Educating pet owners about the benefits of good oral health takes extra time and effort, especially when much of the physical examination is focused on vaccines, nutrition, ear and skin issues, and other presenting problems.
Most discussions and evaluations of oral health are conducted during a pet’s annual wellness examination. However, any opportunity to assess the pet’s oral health is appropriate. When you discuss oral health with clients, remember that it may be the first time they have heard any in-depth information about their pet’s teeth. Take the time to sit down and really get to know the pet’s oral history. Ask open-ended questions about what the pet likes to chew on, what it likes to eat, and whether it has ever displayed any unusual behaviors involving chewing or its face (e.g., excessive drooling, pawing at the face). Listen to the owner’s concerns and ask for descriptions of any facial or chewing behaviors that the pet will not display in the examination room. Owners tend to be unaware of dental issues because the pet continues to eat. You must convey to them that eating is not an accurate indicator of a pain-free mouth. Most patients continue to eat even with severe oral disease.
After a thorough oral history has been documented, the physical examination can be performed. The mouth should be examined last, as patients that tolerate auscultation and abdominal palpation may object to the intrusive act of having their mouth opened. If the patient is very painful or aggressive, mild restraint may be necessary to conduct a proper assessment.
An initial oral examination, without sedation, should include an inspection of the eyes, muzzle, nasal passages, and lymph nodes to detect ocular discharge, suborbital swelling, or nasal discharge. The size and symmetry of the submandibular lymph nodes should be assessed to detect any abnormalities. If possible, the patient’s mouth should be opened to view the tongue and palate. Any lesions, ulcers, defects, discolorations, and masses should be noted. Malocclusions can cause tooth-to-tooth and tooth-to-soft tissue trauma. Proper assessment of the patient’s occlusion requires examination of the teeth, their relation to each other, and the gingival tissue. Discussing findings with owners at the time of the physical examination can help you properly treat the patient on the day of the dental procedure.
The relationship between the credentialed veterinary technician and the veterinarian is instrumental in making this presentation to the client as seamless as possible. The veterinarian is responsible for making the diagnosis and emphasizing the importance and need for treatment. An educated credentialed veterinary technician armed with dental knowledge can point out abnormal findings to both the pet owner and the veterinarian. The team mentality will always help you promote better dental care for your patients.
Addressing Major Concerns and Dispelling Myths
The best way to handle clients who are hesitant about scheduling an oral health procedure is with education and patience. Clients may have all kinds of preconceived notions based on friends’, family, or personal experiences with veterinary dentistry. The only way to calm their fears and address their concerns is to take the time to talk to them and to use your professional knowledge to answer whatever questions they have. Below are some common questions, based on my experience.
Isn’t anesthesia bad for my pet?
When it comes to high-quality dental procedures, the top two concerns are usually anesthesia and cost. These are very sensitive subjects for most owners and are best handled in the privacy of an examination room. This becomes a perfect opportunity to shine and showcase how the practice has addressed them.
As long as your practice is providing high-quality anesthesia, you can be confident in explaining your protocols to owners and reassuring them that you are making anesthesia as safe as possible for their pet. Again, this takes some time and effort; however, the rewards are great for the pet, the owner, and the practice. This is your opportunity to go over the reasons why preanesthetic examinations and bloodwork are required and why intravenous catheters, fluid therapy, and surgical monitoring are important. If you can, it might even help to show owners the dental suite so that they can see for themselves how advanced the equipment is. However, be sure the room is perfect first—owners will pick up on even the smallest flaw, which can lower their confidence in the practice.
Describing your anesthesia protocols is how you can distinguish your practice as a high-quality facility when an owner states they can have a “dental” done for $100 elsewhere. A difference in price often means a difference in quality. You can explain to clients that although almost every practice offers dental services, these services are not necessarily equal from practice to practice.
Isn’t my pet too small for anesthesia?
All dogs and cats are prone to periodontal disease, but in smaller dogs, teeth tend to be crowded or rotated, creating reservoirs for food, hair, and bacteria. Without regular home care, problems requiring professional treatment can result very quickly. Regardless of patient species, breed, or size, proper anesthesia protocols help ensure the safety of all dental patients.
Isn’t my pet too old for anesthesia?
Since pets do not come with expiration dates, it is hard to say how old is too old for a dental procedure. Age is not a disease, but periodontal disease is. As long as the patient is otherwise healthy, has normal physical examination findings, and has normal results on preanesthetic diagnostic tests—and your practice is doing high-quality anesthesia and pain management—there is no reason not to perform a dental procedure in an older pet. If the patient’s health is compromised, further evaluation may be needed before considering an anesthetic procedure. A cardiologist or anesthesiologist can give recommendations for anesthetic protocols that can help avoid negative situations.
Before the dental procedure begins, the veterinarian should assess the patient and assign an ASA (American Society of Anesthesiologists) grade so that everyone involved in the procedure is aware of any increased risks.1 Knowing the patient’s ASA grade allows the anesthetic team to review emergency protocols before any complications can arise.
Why is it so expensive?
Dentistry can be a high-ticket item. It is usually an expense for which owners are not prepared, because most dental procedures are not simply cleanings—they are really major procedures involving oral surgery. Answering this question is another opportunity for you to explain all the protocols your practice follows. A visual step-by-step guide, as described earlier, can be a great asset in addressing many questions owners have about cost.
At the same time, you should help make it possible for owners to treat their pets. Become familiar with pet insurance plans and financing options available in your area. At my practice, we file all the insurance claim forms for our clients. We find that by streamlining the process this way, our clients are reimbursed sooner and with fewer complications. Because insurance claims can be confusing and often require interpretation of medical records, the staff member completing these forms should be knowledgeable about the different companies and plans offered. Most pet insurance companies provide staff education via webinars to help practices stay up-to-date with their policies.
My practice offers two payment plan options to allow owners to schedule payment amounts that fit into their monthly budget. Clients do not want their pets to be in pain or to suffer from untreated oral disease. If given financing options, many owners choose to treat their pets to get them healthy and comfortable.
If my pet were in pain, wouldn’t he/she stop eating?
Many pet owners still hold on to the notion that their pet cannot be in pain because it continues to eat. For years, even people in the veterinary profession assumed this was true, partly because of a fear of anesthesia and even dentistry. We now know that it is not true, and now that we know better, we are obligated to do—and teach—better.
Almost all dogs and cats continue to eat no matter what ailments they are experiencing. This is true for one simple reason—the instinct for survival. To help owners better relate, ask them to put themselves in their pet’s situation: for example, to imagine they are stuck on a deserted island with a broken or abscessed tooth. Would they stop eating? Certainly not! They would continue to eat, drink, breathe, and live day to day. They would not be totally healthy or comfortable, but they would learn how to live with the pain. That is what pets do. Their “desert island” is their inability to communicate in words.
However, you can explain that animals do express pain through their actions. Although they may not be able to say that one of their right lower molars is moving, they may eat their food only on the left side of their mouth. Others may opt to swallow their food whole, shy away from dry food altogether, or stop chewing on their toys. Asking owners to think about whether they have observed these or other abnormal behaviors can help them understand what their pet is “saying” about their oral health.
Owners may tell you that they have always had pets and none of the others needed dental work, or that another veterinarian said oral health was not a problem. Again, this comes down to education and is by no means a reason to let a patient suffer in silence.
My groomer brushes my pet’s teeth. Isn’t that enough?
Some groomers offer toothbrushing as a convenience for owners. However, even with regular grooming, this means that pets have their teeth brushed only every 6 to 8 weeks. Studies have shown that brushing the teeth fewer than 3 to 4 times a week is not beneficial to the overall health of the oral cavity.2
Can’t you do it without anesthesia?
Nonanesthesia dental services are becoming popular among owners as an alternative to cleanings under anesthesia. I believe all veterinary technicians should be aware of the American Veterinary Dental College’s position statement on this practice (see Recommended Reading). A high-quality dental procedure should include charting, scaling, polishing, probing, and radiographic evaluation of all tooth surfaces. Become familiar with the services being offered in your area and how they affect your practice.
On the Day of the Dental Procedure
When an owner comes to drop off a pet for a dental procedure, clear communication is vital. The team must know the owner’s wishes when it comes to consenting to treatment during the procedure. It is best to discuss possible treatment outcomes with owners before or during the procedure so they are not surprised when they come to pick up their pet. You can help avoid problems by requesting all possible contact information for anyone who has the ability to make medical decisions while the pet is under anesthesia. You can also add an option to the practice’s consent forms that allows owners to decide what they would like you to do if they cannot be reached during the procedure despite all efforts to contact them.
It is important to check the pet’s occlusion before intubation and call attention to any abnormalities seen. An overview of normal findings is presented below; credentialed veterinary dental technicians should be familiar with common abnormalities and able to describe them to clients.
A normal bite is called a scissor bite (FIGURE 1). Any deviation results in a malocclusion. The scissor bite is one in which the upper incisors are in front of the lower incisors. The mandibular canine teeth tip out buccally and sit between the maxillary third incisor and the maxillary canine tooth. This space is referred to as the diastema.
Cats and dogs have three basic skull shapes, which are generally dictated by breed. The most common is the mesocephalic. This is a balanced facial profile, seen in breeds such as in German shepherds, Labradors, and domestic shorthairs. The second is the brachycephalic. This produces a shorter snout and an underbite, as is found in pugs, bulldogs, and Persians. The third is the dolichocephalic. These animals have long, narrow muzzles, as in greyhounds, collies, and oriental cat breeds. Knowing how the teeth should line up in a normal occlusion for each skull type makes it easier to identify abnormal occlusions.
Once the patient is safely under anesthesia, a complete oral examination can begin. Knowing the dental formulas for cats and dogs is necessary to accurately assess what is present in the mouth and what is missing (BOX 2). There are two formulas for each species: deciduous and adult. The main difference between these formulas is the addition of molars, which have no deciduous counterparts, to the adult formula. Deciduous teeth, otherwise known as baby teeth, are the first set of teeth to develop in diphyodont mammals. Diphyodont animals have two successive sets of teeth, a deciduous set and a permanent set.
The modified Triadan system (FIGURES 2, 3, and 4) is the currently accepted method for numbering teeth in veterinary dentistry. In adult animals with permanent teeth, teeth in the right upper quadrant are numbered in the 100s; in the left upper quadrant, the 200s; in the left lower quadrant, the 300s; and in the right lower quadrant, the 400s. Charts for juvenile animals with deciduous teeth follow the same pattern, using numbers in the 500s, 600s, 700s, and 800s, respectively. Missing teeth are skipped, as for the upper first premolar and the lower first and second premolars in cats.
For proper recordkeeping, all abnormalities must be noted on the patient’s dental chart, which becomes part of the permanent medical record. Even removal of a deciduous tooth requires notation on a dental chart because the patient’s oral cavity has been evaluated and altered. The chart provides a permanent record of what was done for future reference if the patient returns for other dental procedures. This allows the team to evaluate changes in the oral cavity and adjust treatment plans for teeth being monitored.
Each individual tooth must be evaluated during a dental procedure. Imagine that you have 42 little patients in a dog and 30 little patients in a cat. Each patient needs to be examined and a treatment plan made for it. A periodontal probe and explorer should be used find any defects, periodontal pockets, swellings, and lesions. Any findings should be recorded on the dental chart and discussed with the veterinarian so that the appropriate treatment can be recommended. Dental radiography is essential in determining which teeth can be saved and which are beyond repair.
Cleaning and Radiography
It is important to remove bacteria from the subgingival spaces where periodontal disease begins. A cosmetic cleaning that only addresses the crowns of the teeth is not sufficient. Proper anesthetic protocol, using oxygen and a gas inhalant delivered through a cuffed endotracheal tube to keep an open and protected airway, allows technicians to scale and polish all surfaces of the teeth, both above and below the gumline, safely and effectively.
Dental radiographs are necessary to properly evaluate the health of all tooth and root structures. The crown of a canine tooth is roughly about one-third of the total structure—the tip of the iceberg! Most oral pathology is discovered using dental radiography, and digital dental radiography has become the standard of care when providing high-quality dental services. With proper training, a credentialed veterinary technician should be able to obtain a complete set of dental radiographs in less than 10 minutes for a dog and less than 5 minutes for a cat. This is a skill that must be taught by a trained professional. Once mastered, it becomes an invaluable tool.
Proper positioning and technique is one part of the radiographic assessment; however, interpretation of radiographs requires a separate skill set. This is why it is imperative for the veterinarian and the veterinary technician to work as a team to provide a high-quality oral health procedure for each patient.
Monitoring and Discharge
Once the procedure is complete, it is essential to monitor the patient not only through recovery but also through discharge. Many unfortunate outcomes are due to poor anesthetic monitoring or poor recovery protocols. In my experience, it is valuable to keep the intravenous catheter in place until the patient is discharged in case of an emergency situation.
Owners should meet with the veterinarian or veterinary technician after the procedure to discuss everything that was done during the procedure. This is the perfect time to showcase the practice’s quality of care by giving the owner copies of the digital pictures and radiographs of the pet’s mouth. These images show the extent and value of what has been done and give the owner something to refer to when checking on the pet’s home care progress. The owner should also receive printed discharge instructions that outline short-term home care instructions, such as how to administer postprocedure medications, as well as long-term guides to maintaining the pet’s oral health and developing a home oral care regimen. Presenting all this information in a packet is truly your opportunity to shine.
It is up to veterinary technicians to make sure owners are properly educated on how to care for their pet’s mouth at home. Ideally, this should be done at the time of discharge, again at the recheck visit, and later through a callback system. A callback system enables you to reach out to owners, ask how the home care regimen is going, and support them in taking care of their pet’s oral health. If the owner has not been successful with your initial home care recommendation, you can discuss other options. For example, if a pet will not cooperate with toothbrushing, or if an owner cannot fit brushing into their schedule, dental wipes or chews, oral gels or rinses, dental diets, or food or water additives may be easier options. In these cases, it may be best to recommend a recheck visit to assess the oral cavity.
Once owners realize that their pet’s oral health is important to your practice, they will begin to believe in its value. Veterinary technicians can no longer ignore the fact that oral care is integral to the overall health and well-being of all our patients. We should start being proactive rather than reactive when it comes to dental issues. By starting the conversation with owners from their very first visit, we can teach them that oral health is an important part of our complete care for their pet.
If we do a better job of communicating the importance of dental care and the signs of dental disease to our clients, we have a better chance of increasing owner compliance when it comes to oral care. It is my dream that within the next 20 years, we will not have to spend so much time convincing pet owners that dental care is integral to their pets’ health. They will have learned that home care should be part of a daily routine and that professional oral cleanings should be performed regularly.
- Academy of Veterinary Technicians in Anesthesia and Analgesia. American Society of Anesthesiologists (ASA) Physical Status Scale. Accessed December 1, 2015. www.avtaa-vts.org/asa-ratings.pml.
- Tromp JA, van Rijn LJ, Jansen J. Experimental gingivitis and frequency of tooth brushing in the beagle dog model. Clinical findings. J Clin Periodontol 1986;13(3):190-194.