Dentistry is an exacting science that requires attention to detail. Not all pet dental cleanings are created equally. This article discusses the important components of the professional dental cleaning. Why Anesthesia? This will be a topic of an upcoming stand-alone article, but for now, suffice it to say that no self-respecting dog or cat will allow you to do a thorough subgingival scaling, a complete oral and pharyngeal exam, and dental radiographs when awake! Click here to read tips on how to make anethesia safer. Risk vs. Benefit Much of what I do as a veterinary dentist involves assessing the risk vs. benefit for an elective dental procedure in a patient that may have an inherently higher anesthetic risk than a healthy patient. Veterinary dentists tend to surround themselves with people and machines that help minimize that risk. Click here to watch a three-year-old miniature schnauzer undergo a dental cleaning and extraction. But risk is present even in healthy patients. Appropriate preoperative diagnostics help to assess risk. Step 1: Safety First The cuffed endotracheal tube is checked prior to starting the dental procedure. Care should be taken to inflate the cuff to prevent leaks, but we need to avoid filling the cuff excessively to avoid tracheal rupture and necrosis. How many milliliters of air are required to fill the cuff of a typical cat? Approximately 1.6 +/- 0.7 milliliters.1 How many milliliters of air are required to rupture the trachea of a cat? Approximately 6 milliliters.1 Therefore, using a 3 cc syringe to inflate the cuff is more appropriate than a 10 cc syringe for a cat. The eyes of the patient are protected with copious amounts of eye lubricant. The operator wears a protective mask and eye protection. The mouth is rinsed with 0.12 percent chlorhexidine solution (much less concentrated than what is used on skin) to decrease bacterial aerosolization. The patient is positioned to provide optimal ergonomics to prevent acute and chronic injury to the operator. Step 2: Oral Examination Start with an examination of the extraoral structures including palpation of the mandibular lymph nodes, salivary glands of the neck, retropulsion of the eyes, inspection of the nares, maxilla and mandibles. Intraoral structures are evaluated, including the tongue, palate, pharynx, tonsils, buccal, labial, and alveolar mucosa. Each tooth is evaluated for presence/absence, mobility, fractures, discoloration, abrasion, attrition, caries (cavities), resorption and pulp exposure. These findings are recorded on the dental record. Each tooth is evaluated with a probe and an explorer. The probe checks for periodontal pockets in six areas around the circumference of the tooth. The explorer is particularly important in evaluating the gingival margin in cats to assess for subtle tooth resorption, and for evaluating whether a fractured or abraded tooth has pulp exposure. These observations, as well as comments on degree of periodontal disease, are noted on the dental record. Dental Radiographs At the University of Pennsylvania, full mouth radiographs are obtained in all cats and most dogs. Multiple studies have shown there is significant diagnostic value to obtaining dental radiographs.2,3 You are only seeing approximately half of the tooth structure without dental radiographs. Step 4: Clean Supragingivally A laparotomy sponge is placed in the back of the pharynx to absorb liquids, and the nose of the patient is pointed down in relation to the neck to allow fluids to flow outward instead of into the pharyngeal area. An ultrasonic scaler designed for supragingival use removes heavy calculus from the crowns of the teeth. Avoid using the scaler on a single tooth for more than 20 seconds to avoid thermal or vibrational damage to the tooth. Step 5: Clean Subgingivally Next, an insert intended for subgingival use (with a “perio” tip) is utilized within the gingival sulcus of each tooth to remove any subgingival calculus. Hand curettes may be used subgingivally in areas where periodontal pockets require subgingival curettage and root planing. Hand scalers may be used in areas where calculus is adherent in developmental grooves of the tooth crowns. Perform appropriate periodontal therapy, periodontal surgery, and extractions as indicated by clinical signs, radiographs and oral exam. Polish the Teeth Well, But Not Too Much Polishing allows for removal of microscopic etches on the surface of the tooth created by the cleaning process. Enamel loss may occur due to excessively frequent polishing, and overaggressive polishing (too much pressure or excessive RPMs) may result in thermal damage to a tooth. Use light pressure, just enough to flare the cup of the prophy angle, and polish for one to three seconds on each tooth surface, returning to the surface for another one to three seconds as needed to polish all surfaces. Rinse the polish off by a gentle rinse of water from the air-water syringe. Step 7: Consider Applying Something I do not typically apply fluoride to the teeth after a cleaning because caries are rare in our veterinary patients. Barrier sealants are available that may be applied to the teeth after a professional dental cleaning. Sanos is a liquid sealant that is coated on the teeth and subgingival area after polishing. This product has received the Veterinary Oral Health Council (VOHC) seal of acceptance for plaque and calculus reduction. OraVet is a plaque and calculus prevention system that has been shown to significantly decrease plaque and calculus formation at four and eight weeks after application.4 Step 8: Show Owners What You Did Show clients dental radiographs and before-and-after photos of the work you did on their pet. The educational values of images cannot be underscored enough! Step 9: Recommend a Custom-made Home Care Strategy Daily or twice-daily brushing is the gold standard of home care. Many pets will tolerate brushing with some practice. Some keys to pass along to pet owners: • Pets don't like having their mouths open, so lift the lip without opening the mouth to allow for access to the outer surface of most upper and lower teeth; • Use a soft-bristled brush with nothing on it but warm water at the beginning; • Use a circular motion with bristles angled toward the gingival margin to allow some bristles to sweep beneath the gingiva; • Save the inside surfaces of the teeth for the last part of brushing; • Give the pet a treat after brushing as positive reinforcement. Not every pet and pet owner can form a compliant brushing team, for a variety of reasons. Rinses and gels are available that may provide anti-plaque and anti-calculus effects. Special dental diets have an effect either mechanically or due to chemicals that retard plaque or calculus accumulation. Chewing on appropriate chew toys and treats may help in chewing-motivated patients. Water additives are also available. Some of the above products have received the VOHC seal of acceptance for either plaque or calculus reduction, or both. See www.vohc.org/accepted_products.htm for a full list of VOHC-accepted products. How Often? I am commonly asked how frequently a dog or cat should receive an anesthetic dental cleaning. There is not a “canned” answer to this question. Patients are different in how quickly they develop calculus, plaque and periodontal disease. Most patients will benefit from a yearly professional dental cleaning; some may need more frequent care. Some patients may need less frequent cleanings, especially if effective home care is occurring between cleanings. John Lewis, VMD, FAVD, Dipl. AVDC, is assistant professor of dentistry and oral surgery at the University of Pennsylvania School of Veterinary Medicine in Philadelphia. REFERENCES and RECOMMENDED READING 1. Hardie EM, Spodnick GJ, Gilson SD, Benson JA, Hawkins EC. Tracheal rupture in cats: 16 cases (1983-1998). J Am Vet Med Assoc. 1999 Feb 15;214(4):508-12. 2. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in cats. Am J Vet Res. 1998 Jun;59(6):692-5. 3. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res. 1998 Jun;59(6):686-91. 4. Gengler WR, Kunkle BN, Romano D, Larsen D. Evaluation of a barrier dental sealant in dogs. J Vet Dent. 2005 Sep;22(3):157-9. Holmstrom SE, Bellows J, Colmery B, Conway ML, Knutson K, Vitoux J. AAHA dental care guidelines for dogs and cats. J Am Anim Hosp Assoc. 2005 Sep-Oct;41(5):277-83. Lewis JR, Miller BM. Dentistry and Oral Surgery. In: Bassert JM, McCurnin DM, eds. Clinical Textbook for Veterinary Technicians, 2010. Saunders Elsevier, St. Louis, MO, pp 1093-1148.
