2013 AAHA Dental Care Guidelines for Dogs and Cats*

Introduction

Veterinary medical dental care is an essential component of a preventive healthcare plan. Quality dental care is necessary to provide optimum health and quality of life. If left untreated, diseases of the oral cavity are painful and can contribute to other local or systemic diseases.^1,2 The purpose of this document is to provide guidelines for the practice of companion animal dentistry. A list of definitions to enhance the understanding of this article is provided in Table 1.

Table 1 Definitions that Pertain to Dental Guidelines*

*

Some of these definitions were derived from descriptions in Holmstrom et al. (2004).³

View Fullscreen

The dental health care team is obligated to practice within the scope of their respective education, training, and experience. It is imperative that the dental health care team remains current with regard to oral care, operative procedures, materials, equipment, and products. The team members must attain appropriate continuing education through courses such as those offered by the American Animal Hospital Association, the American Veterinary Medical Association, the annual Veterinary Dental Forum, industry and private facilities; by reading the Journal of Veterinary Dentistry; and by reading other appropriate journals and medical texts.^3–7

Facility Requirements

Dental procedures result in aerosolized bacteria and particulate matter. Using a dedicated space is recommended for nonsterile dental procedures. The dedicated dental space must be separate from the sterile surgical suite and needs to be placed in a low-traffic area. New practices and those planning on remodeling should incorporate a separate dental suite into the blueprint.

Appropriate ventilation and anesthetic scavenging systems must also be used. Low-heat, high-intensity lighting, and equipment for magnifying the target area are required to adequately and safely visualize the oral cavity and its structures. The operating table must allow for drainage and be constructed of impervious, cleanable material.

Materials, Instruments, and Equipment

As with dental techniques, it is important to keep the dental materials up-to-date and veterinarians must be aware of what materials are considered appropriate for the treatment of dental conditions. Commonly used materials can be found by consulting a dental text and attending continuing education programs presented by a dental specialist.

Instruments and dental equipment require routine and frequent maintenance. Maintenance information can be found in some dental texts and through the manufacturer. Instruments must be sharp and properly stored, and instruments in poor condition need to be replaced. A written protocol needs to be established and followed for equipment and instrument care.

As with human dentistry, instruments that enter the oral cavity should be sterilized. Packets organized by dental procedure (e.g., examination, extraction, periodontal surgery) should be prepared and sterilized before use.

Recommended materials, instruments, and equipment for performing dental procedures are listed in Tables 2 and 3. Consult the reference list associated with these guidelines for recommendations and information on ordering equipment.^3–7

Table 2 Materials Needed for the Practice of Veterinary Dentistry*

*

Please note that disposable items are for single use only.

View Fullscreen

Table 3 Instruments to Include in the Dental Surgical Pack*

*

Instruments must be sterilized by accepted techniques prior to each use. Hand instruments must by properly sharpened and cared for.

View Fullscreen

Operator Protection

Pathogens and debris such as calculus, tooth fragments, and prophy paste are aerosolized during dental procedures. Irrigating the oral cavity with a 0.12% chlorhexidine solution before dental scaling decreases bacterial aerosolization.⁸

The safety of the operator must be ensured during dental procedures by using radiographic, oral, respiratory, skin, eye, and ear protective devices (Table 4). Ergonomic considerations include proper seating, fatigue mats for standing, and proper positioning of both the patient and materials to minimize immediate and chronic operator injuries. Provide the operator with instruction on proper instrument handling techniques.

Table 4 Minimum Protective Devices to be used During Dental Procedures

View Fullscreen

Patient Assessment

Oral/Dental Examination in the Conscious Patient

Record all findings in the medical record (Table 5). Evaluate the head and oral cavity both visually and by palpation. Changes in body weight, eating habits, or other behaviors can indicate dental disease. Specific abnormal signs to look for may include pain; halitosis; drooling; dysphagia; asymmetry; tooth resorption; discolored, fractured, mobile, missing, or extra teeth; inflammation and bleeding; loss of gingiva and bone; and changes in the range of motion or pain in the temporomandibular joint. In addition, the practitioner should assess the patient’s occlusion to ensure it is normal, or at least atraumatic. Evaluate the patient’s eyes, lymph nodes, nose, lips, teeth, mucous membranes, gingiva, vestibule (i.e., the area between the gum tissue and cheeks), palatal and lingual surfaces of the mouth, dorsal and ventral aspects of the tongue, tonsils, and salivary glands and ducts. Note all abnormalities such as oral tumors, ulcers, or wounds. A diagnostic test strip for the measurement of dissolved thiol levels can be used as an exam room indicator of gingival health and periodontal status.¹⁴

Table 5 Items to Include in the Dental Chart and/or Medical Record

View Fullscreen

The oral examination performed on a conscious patient allows the practitioner to design a preliminary diagnostic plan. Take into consideration potential patient pain. Do not offend the patient by probing unnecessarily when such manipulations can be better achieved under anesthesia. Also, realize in many instances that the examiner will underestimate the conditions present because it is impossible to visualize all oral structures when the patient is awake. It is only when the patient has been anesthetized that a complete and thorough oral evaluation can be accomplished successfully. The complete examination includes a tooth-by-tooth visual examination, probing, and radiographic examination. Only then can a precise treatment plan and fees for proposed services be tabulated and discussed with the pet owner(s).

Making Recommendations and Client Education

Discuss the findings of the initial examination and additional diagnostic and/or therapeutic plans with the client. Those plans will vary depending on the patient; the initial findings; the client’s ability to proceed with the recommendations; as well as the client’s ability to provide necessary, lifelong plaque prevention.

When either an anesthetic examination or procedure is not planned in a healthy patient, discuss preventive healthcare, oral health, and home oral hygiene. Options include brushing and the use of dentifrices, oral rinses, gels and sprays, water additives, and dental diets and chews. Discourage any dental chew or device that does not bend or break easily (e.g., bones, cow/horse hooves, antlers, hard nylon products). The Veterinary Oral Health Council lists products that meet its preset standard for the retardation of plaque and calculus accumulation.¹⁵ Illustrate to the owner how to perform oral hygiene, such as brushing, wiping teeth, application of teeth-coating materials, and the use of oral rinses and gels. Allow the client to practice so they will be able to perform the agreed-upon procedure(s) at home.

All home oral hygiene options, from diet to the gold standard of brushing, along with any of their potential limitations need to be discussed with the client. It is essential that the oral health medical plan is patient-individualized to attain the greatest level of client compliance. For example, “dental” diets and chews can be used until the client is comfortable either brushing or applying an antiplaque gel, rinse, or spray with a wipe. The gold standard is brushing the pet’s teeth using a brush with soft bristles either once or twice daily. If the client is either unable or unwilling to persevere with brushing, use any of the other oral hygiene options that the patient will tolerate.

Explain the two-part process involved in a diagnostic dental cleaning and patient evaluation to the client. It is critical that he/she understand the hospital protocol to minimize miscommunication and frustration. The procedure involves both an awake component and an anesthetized component for a complete evaluation. It is not until the oral radiographs have been evaluated that a full treatment plan including costs of the anticipated procedure(s) can be successfully made with any degree of accuracy.

Evaluation of a patient for dental disease involves the awake procedure as the first step. This is where an initial assessment is made. Although many problems may be seen at this point of the evaluation, a thorough diagnosis and treatment plan cannot be determined until charting, tooth-by-tooth examination of the anesthetized patient, and dental radiographs have been taken and evaluated. Studies have demonstrated that much of the pathology in a patient’s oral cavity cannot be appreciated until dental radiographs are taken and assessed; therefore, have protocols in place within the practice to give clients ample time to make an informed decision on how they want to proceed with the proposed treatment plan.¹⁶

Some hospitals may want to do the awake examination and the anesthetic component (charting, cleaning, and dental radiographs) as the first procedure. They can then stage the treatment plan as a second procedure. This will give the hospital staff adequate time to explain to the client the treatment plan, including giving educational information on the diagnosis, reviewing radiographic findings, and going over costs. Other hospitals may want to perform the treatment plan during the first anesthetic event so everything is done at that procedure. Whichever way the hospital chooses, there must be a client communication plan in place so the client is involved and feels comfortable going forward with the proposed treatment plan.

Perform the anesthetized portion of the dental evaluation of charting, cleaning, and radiographs when abnormalities are seen on the awake exam (such plaque or tartar at the free gingival surface of the maxillary canines or fourth premolars) or at least on an annual basis starting at 1 yr of age for cats and small- to medium-breed dogs and at 2 yr of age for large-breed dogs. Details on the recommended frequency of examinations are discussed under Progress or Follow-Up Evaluation (below).

Planning the Dental Cleaning and Patient Evaluation

Use well-monitored, inhalation anesthesia with cuffed intubation when performing dental cleanings. Such techniques increase safety, reduce stress, decrease the chances of adverse sequelae (e.g., inhalation pneumonia), and are essential for thorough and efficient evaluation and treatment of the patient. Attempting to perform procedures on an awake patient that is struggling, under sedation, or injectable anesthesia reduces the ability to make an accurate diagnosis, does not allow adequate treatment, and increases stress and risks to the patient.

Dental Procedures

The terms prophy, prophylaxis, and dental are often misused in veterinary medicine. A professional dental cleaning is performed on a patient with plaque and calculus adhered to some of the teeth, but otherwise has an essentially healthy mouth or mild gingivitis only. The intent of dental cleaning is to prevent periodontitis. Patients with existing disease undergo periodontal therapy in addition to professional dental cleaning. Dental procedures must be performed by a licensed veterinarian, a credentialed technician, or a trained veterinary assistant under the supervision of a veterinarian in accordance with state or provincial practice acts. Practice acts vary from jurisdiction to jurisdiction, and the veterinarian must be familiar with those laws. Surgical extractions are to be performed only by trained, licensed veterinarians. All extractions need to have postextraction, intraoral radiographs. All dental procedures need to be described properly (Table 1), and a consistent method should be used to record findings in the medical record (Table 5).

Positioning and safety of the patient is important. Manually stabilize the head and neck when forces are being applied in the mouth. Avoid using mouth gags because they can cause myalgia, neuralgia, and/or trauma to the temporomandibular joint. If a mouth gag is necessary, do not fully open the mouth or overextend the temporomandibular joint. Never use spring-loaded mouth gags. Do not overinflate the endotracheal tube. Always disconnect the endotracheal tube when repositioning the patient to prevent trauma to the trachea.

Postoperative Management

Maintain an open airway via intubation until the animal is either swallowing or in sternal recumbency. Maintain body temperature and continue IV fluid support as needed. Continuously monitor and record vital signs until the patient is awake. Assess and record pain scores throughout the recovery period, continuing pain management while the pet is in the hospital and upon discharge.^34,44

Client Education and Follow-up

Progress or Follow-up Evaluation

With each follow-up examination and telephone communication, repeat the home dental care instructions and recommendations to the client. Set the number and timing of regular follow-up visits based on the disease severity. Although few studies have been performed in dogs and cats, extrapolation from the human literature and guidelines about aging in dogs and cats leads to the following recommendations:¹⁴

• Dental health care needs to be part of the preventive healthcare examination discussion and should begin at the first appointment at which the patient is seen and continue routinely throughout subsequent exams.

• Examinations q 6 mo can help ensure optimal home oral hygiene. At a minimum, evaluate animals with a healthy mouth at least q 12 mo.

• Evaluate pets with gingivitis at least q 6 mo.

• Evaluate pets with periodontitis at least q 3–6 mo.

• Advanced periodontal disease requires examinations q 1 mo until the disease is controlled.

Evaluate disease status, such as periodontal disease, on the conscious patient with products that allow an assessment of periodontal health without placing the patient under anesthesia.¹⁴ During subsequent examinations, evaluate client compliance, revise the treatment plan as needed, and redefine the prognosis.

Nutrition

Nutrition plays an important role in oral health; therefore, it is important for the healthcare team to have an understanding of the impact of nutrition on their patients. A properly balanced diet is essential for good general health, including health of oral tissues. For good oral health, it is the form of the diet, not the nutritional content, that is critical for good oral health. A diet that provides mechanical cleansing of the teeth is an excellent way of retarding the accumulation of dental plaque and calculus. Dental diets and chews can be very effective if the owner is unable to brush the teeth. Dental diets work either by “brushing” the crowns of the teeth as the animal chews or by coating an anticalculus agent on the surface of the teeth. Nutrition becomes even more critical in dental health when the client is unable to provide home oral hygiene by brushing.⁴⁷ During subsequent examinations, evaluate client compliance, revise the treatment plan as needed, and redefine the prognosis.

Conclusion

Pets can live more comfortable lives if oral health care is managed and maintained. All members of the veterinary team must strive to increase the quality of dental care delivered. Clients must be given options for the optimal care and treatment available for their pets. Dentistry is becoming more specialized, and referral to a veterinary dental specialist or a general practitioner with advanced training and proper equipment is recommended if the necessary expertise and/or equipment are unavailable at the primary veterinarian’s office.