It’s February! A whole month full of hearts, flowers, pink and red hand-made cards, sugary stomach aches, tarter and halitosis. I am not referring to an awkward conversation you need to have with your hubby. The AVMA deemed February National Pet Dental Health Month in an effort to draw pet owners’ attention to the importance of their pet’s oral health. This month we veterinary professionals have the opportunity to discuss the importance of a full oral exam and the systemic sequelae to dental and periodontal disease. Once we have convinced our clients that oral health is important, what do you suppose is the number one reason that clients decline dental services for their pets? Based on the recent upswing of anesthesia free teeth cleaning services for pets*, (a procedure not condoned by the American Veterinary Dental College), I am willing to bet that it is not financial concerns but more often fears of anesthetic risk that keep pets from getting dental care. A 2006 UK study done over two years involving 98,036 dogs, 79,178 cats and 8,209 rabbits showed that the procedures that most commonly resulted in death were1:
- Exploratory laparotomy (Dogs)
- Spay for pyometritis (Dogs)
- Dental surgery (Dogs & Cats)
- Spay (Cats)
- Diaphragmatic hernia repair (Cats)
- Treatment for urethral obstruction (Cats)
- Repair of jaw fractures (Cats)
Is it surprising to find that dental surgery ranks third on that list? A patient undergoing a dental procedure is inherently at greater anesthetic risk for several reasons.
- Age-many patients requiring a dental cleaning are older and may have concurrent disease processes. Older animals may also have less ability to compensate for hypothermia and hypotension.
- Systemic disease-a correlation can be drawn between dental disease and some systemic diseases which puts those dental patients at greater risk.
- Anesthetic depth-patient stimulation can vary greatly within a short amount of time during these procedures which can lead to a patient’s anesthetic dose being increased and not appropriately decreased.
- Anesthetic time-dental procedures can take hours, rarely taking less than 45 minutes in the best of circumstances.
- A fair amount of head manipulation needs to be done during the procedure which can put the intubated patient at risk for tracheal tear.
- Use of water cooled instruments puts the patient at greater risk for aspiration of water or bacteria-laden tartar, drenching the patient’s head leading to hypothermia
I am certainly not trying to scare everyone away from having dental procedures performed on their pets and ruining February for everyone. On the contrary, I understand how important oral health is to an animal's overall health and would like to discuss how we can make dental procedures safer for our patients.
Be prepared. A lot of these risks can be mitigated with awareness and preparedness. Make sure that a proper pre anesthetic work up has been done including full physical exam and lab work. If you anticipate the patient having hypotensive challenges, discuss a plan with your doctor for that event prior to anesthesia. Will that event by managed with a decreased inhalant dose, colloids, vasopressors, crystalloid boluses or a combination of these things?
Turn down the gas. How can you turn the gas down when you are constantly stimulating the patient? Use local blocks when possible! This will help you lessen a few different risks. If the patient’s nerves are blocked, the anesthetist will need to adjust the inhalant gas concentration much less often. This will decrease the chances of accidental overdose. Another benefit to the nerve block is a lower mean alveolar concentration of inhalant gas needed and therefore a lower risk of an anesthetic related hypotensive episode. Some anesthetists have experienced patients pawing at their faces upon anesthetic recovery after receiving a dental block. I recommend using lidocaine instead of longer acting bupivicaine in most cases when performing dental blocks.
Make your patient warm. Combating hypothermia is more than keeping your patient warm. In the case of an anticipated long anesthesia and a wet patient, pre warming your patient may be necessary. I have heard of a few creative ideas for keeping patients warm during dental procedures.
- Put your patient on a mat. Laying them on a towel on the wet table is convenient to give all of that water somewhere to go, but also provides more surface area to lose body heat via radiation. Placing the patient's body on a solid surface (like a mat) will help.
- Heating pads- placing your patient on any type of approved heating pad will help slow down heat loss via conduction.
- Preventing heat loss via convection can be done in many creative ways
- Bubble wrap layers over the patient to hold heat in
- Baby socks on feet to keep heat in
- Emergency reflective blanket tented over patient to trap heat in
- Fighting evaporative cooling (especially on the wet head) during a dental is really difficult. Attempt to keep the head as dry as possible and take time to wipe dry periodically.
- Administering warm IV fluids and warming inhaled gases will not go a long way in warming a hypothermic patient, but will slow heat loss and both treatments are recommended.
It takes two. In case you have not guessed, I believe that two technicians should be responsible for a dental patient, one anesthetist and one dental hygienist. The anesthetized patient should have its vitals recorded every five minutes according to AHAA standards. As an anesthetist, I record data points every five minutes and when there are changes in the patient's vital signs, fluid rates, anesthetic rates, or medications given. Monitoring anesthesia is a full time job all by itself! It is not efficient or safe for the patient if the technician stops a dental cleaning procedure every five minutes to record data. Another benefit to a dedicated anesthetist is reduced risk of tracheal tear with two people to remind each other to disconnect the endotracheal tube from the anesthetic machine every time the head is moved.
If two technicians are not available another option may be for the technician to perform the dental while an assistant records the patient's vitals and simultaneously reports them to the technician. I am not advocating assistants monitoring anesthesia. The assistant is recording data and relaying that information to the technician. It is the technician making the decisions about what to do with the data given. This method is not an ideal situation, but I feel it is better than one person doing two jobs.
I am embarrassed to admit that I myself am guilty of neglecting dental care for my beloved pets due to safety concerns. As an anesthesia specialist I know how safe we are able to make anesthesia. I also know that the safest anesthetized patient has a dedicated anesthetist attached to it which is often not the case during a dental procedure. Recently there has been a push toward anesthetic safety and I am happy to report that a growing number of facilities do perform dental prophies with a dedicated anesthetist, but in many facilities this is still not the case. As an emergency and critical care specialist, I see quite a few patients admitted to the hospital with complications arising from a recent dental procedure and a dedicated anesthetist can make a difference.
It is my hope that this article has given you some ideas about how to make dental procedures safer for your patients. You may also have gained discussion points regarding dental anesthesia that will calm your client’s fears and get more teeth cleaned this month as a result! Now I have a kitty dental to schedule. If a super stressed lady calls you and asks you a hundred questions about dental anesthesia, tell me to relax and that you have read this article.
* This is a procedure typically performed by personnel who have not been medically trained and are not working under the supervision of a veterinarian. The procedure involves some scaling and sometimes polishing of the teeth but does not:
protect the patient airway from aspiration of water or bacteria laden tarter
involve a full oral exam done by a veterinarian
provide enough opportunity to clean the lingual and palatal surfaces of the teeth
keep the handler safe from patient bites
1. Brodbelt DC (2006) The Confidential Enquiry into Perioperative Small Animal Fatalities. PhD thesis. Royal Veterinary College. London university, London UK