So does a dental on the ops list fill you with joy, or is it quite the opposite? Whether veterinary dentistry is your ‘thing’ or not, here are 10 top tips to help you through those difficult dentals.
1. Allow enough time
Dentals are often last on the list, filling the slot before lunch when blood sugar levels are low and afternoon consults are looming. While keeping ‘dirty’ ops until last is a sensible policy, rushing through a dental is not to be recommended. It is almost impossible to fully assess the mouth of a conscious canine, so every dental should have adequate time allotted; there is no such thing as a ‘quick’ dental.
2. Have the right veterinary dental equipment
Having the right dental equipment, and sharp hand instruments is essential for successful extractions. Without the appropriate tools, dentals will take longer and be more challenging, with an increased likelihood of complications like root fractures.
- Elevators should be sharp and of a suitable size.
- New burrs in a range of sizes for root sectioning are essential.
- A high-speed, water-cooled drill is needed, both for root sectioning and removal of alveolar bone.
- Extraction forceps should be of a size that is comfortable for the veterinary surgeon, and suitable for the patient and tooth in question. They should only be used when the root is sufficiently mobile.
3. Plan ahead
Having knowledge of tooth structure and root anatomy at the tips of your fingers will help you plan. Knowing the number of roots for each tooth, and the location of the furcation angle for sectioning is essential. As a rule, three-rooted teeth are only found in the maxilla, but it is advisable to refer to a dental anatomy text, and remember that there are individual variations.
4. Veterinary dental radiography
Full mouth intraoral dental radiographs should be taken to evaluate the alveolar bone plus root and tooth structure. Not only will this help with planning, but it will also ensure that painful pathology is not left untreated.
5. Multi-rooted teeth should be sectioned
All multi-rooted teeth should be sectioned prior to attempting extraction, and knowing root anatomy is essential here. Gentle pressure only is best for all extractions, with rotation gradually weakening and stretching the periodontal ligament. Patience is key, and only once the root is mobile should extraction using dental forceps be attempted.
6. Surgical extraction
Performing an open or surgical extraction, will almost always take less time than a closed extraction, especially with multi-rooted teeth. The tooth should be sectioned into individual roots and a mucoperiosteal flap raised, with the aim of exposing the root. The flap should be full thickness and a periosteal elevator used to elevate the flap beyond the mucogingival line:
- Avoid excessive handling of the flap, especially the edges to help preserve flap viability
- Flaps with a broad base will tend to have better blood supply than those with a narrow base
- Using a sharp periosteal elevator directed towards the bone will reduce the risk of flap perforation
7. Staged dentals
Where there is extensive disease, dental staging can be considered. Staging can be useful where there are concerns about the length of a procedure and any associated increase in anaesthesia risks. However, much of this risk can be mitigated by careful monitoring of anaesthesia and the use of supportive measures such as intravenous fluids and adequate patient warming. When dental work is staged it is important to treat any teeth that are severely affected and causing pain during the initial procedure, and the second stage should be scheduled without undue delay.
8. Before and after photos to show owners
Communicating with owners is aided by showing them intra-oral photos of their pet’s mouth, both before and after the dental work. Photos can be particularly useful when dentals have had to be staged, to illustrate to owners what needs to be done during the second procedure.
9. Have a go-to product for stopping bleeding
Bleeding from extraction sites can often be controlled by applying pressure with a moistened swab. However, it is important to have a haemostatic agent available as well to aid control of more protracted bleeding. Haemostem™ Dental Cubes contain carboxycellulose, and are designed for packing dental extraction sites.
10. Good analgesia is imperative
And finally, good analgesia is a priority, and should be pre-emptive and multi-modal. As well as appropriate use of opioids and non-steroidal anti-inflammatories, local anaesthesia is beneficial. The use of loco-regional anaesthetic techniques, such as dental nerve blocks, contributes to balanced anaesthesia, reducing the requirement for inhaled anaesthetic agents as well as increasing patient comfort post-operatively.
- Kortegaard, H. E. et al., (2008) Periodontal disease in research beagle dogs – an epidemiological study. Journal of Small Animal Practice 49, 610- 616