Recently, I received an email from a pet owner, David, who lives on the West Coast. He was seeking advice for Molly, his 9-year-old Bichon Frise who was recently diagnosed with severe periodontitis. For several years, David has been having anesthesia-free dental cleanings done yearly for Molly, and the most recent time he took Molly, the dental service recommended he seek professional veterinary dental care due to severe progression of Molly’s dental disease. David decided to take his pet to a veterinary dentist for a thorough oral examination under anesthesia. The 42 teeth were individually assessed with a periodontal probe, and pocket depths were assessed at multiple sites around each tooth. Full-mouth intraoral dental radiographs were obtained. These tests allowed the veterinary dentist to diagnose severe periodontitis with a combination of severe horizontal and vertical bone loss. Endodontic disease (tooth root abscesses) was seen on multiple teeth due to extension of periodontal disease. Second Opinion David was shocked to hear that periodontitis, bone loss and secondary endodontic disease would require extraction of 21 teeth. He contacted us for a second opinion, because he was willing to do anything possible to save these teeth, even if that required flying Molly across the country to have specialists at the University of Pennsylvania perform bone augmentation or guided bone regeneration techniques. I looked at the dental chart and radiographs taken just days prior, and I quickly realized that no amount of time or money could save these severely affected teeth. I agreed wholeheartedly with the assessment of the veterinary dentist on the West Coast: These teeth were too far gone to save. I wish this were just an isolated case, but I am regularly asked to consult on these types of cases. And I am not the only one who sees these patients. When a patient has had years of anesthesia-free cleanings, the crowns of the teeth often look very clean and devoid of plaque, calculus and sometimes even devoid of gingivitis. However, beneath the gingival margin, these patients’ teeth tend to show quite a few surprises. David was dismayed because his primary care veterinarian recommended anesthesia-free cleanings. "I should have thought for myself and realized anesthesia-free cleanings are merely superficial, given their obvious limitations. Moreover, dental radiographs, if done years ago, may have identified the true degree of disease and prevented or at least delayed this outcome.” Definitions Although the term "anesthesia-free dentistry” is commonly used to describe this practice, the American Veterinary Dental College prefers to use the term "non-professional dental scaling,” or NPDS, to describe these procedures. Here are a few reasons why NPDS is not a good idea: 1. Dental procedures can be uncomfortable. It is rare for a professional dental cleaning in our veterinary patients to be "just a cleaning.” When you look closely with the right tools, you often find pathology. This pathology may be in the form of a periodontal pocket that requires closed root planing and subgingival curettage. Even a thorough subgingival ultrasonic cleaning can cause some discomfort. We don’t want our patients to feel pain during treatment if possible. 2. A thorough oral examination requires anesthesia. A thorough oral examination is one of the most important services we can provide. Some structures simply cannot be visualized in the conscious patient, such as the tonsils and pharynx. We’ve seen numerous patients with oral cancer who were diagnosed and treated earlier due to an incidental finding during a thorough anesthetized oral exam. When checking teeth for fractures and tooth resorption, a sharp explorer is used that might cause pain in the conscious patient. When examining each tooth, a periodontal probe is submerged into the gingival sulcus in six places around each tooth. No self-respecting dog or cat will let you do that while awake. 3. Dental radiographs elevate the level of care. Ask anyone who recently purchased a dental X-ray system for their hospital, and they will tell you that dental radiography has elevated their level of diagnostic and therapeutic care. Dogs and cats simply do not tell us when a tooth root abscess is brewing, until their faces swell to two times normal size. Even then, appetite of these patients is still good. 4. Scaling requires thorough polishing. Scaling with either a hand instrument or an ultrasonic scaler causes microscopic scratches on the surface of the enamel. If your patient is a moving target as you are scaling, the potential for damage to surface enamel is even greater. Polishing with a prophy cup and prophy paste or pumice will smooth rough surfaces, provided that the patient stays still enough to allow for a thorough polishing of the entire surface of the tooth. 5. False sense of security. When the crowns of the teeth are clean, we assume all is going well beneath the gingival margin. The accumulation of plaque and calculus on the teeth give us an external clue that it’s time to consider a professional dental cleaning. For Molly and other dogs that have regular non-anesthetic cleanings, it is difficult to know there is a problem. At some point, once irreversible changes have occurred, it finally becomes apparent that more needs to be done. It’s the subgingival area that requires the most attention during a dental cleaning. But this area is least accessible in the conscious patient. Veterinarians must make a risk-benefit assessment when deciding if the benefit of a thorough oral examination and professional dental cleaning outweigh the risk of anesthesia. Weighing Pros and Cons There is always at least a small risk with anesthesia, which may be a great risk depending on the medical status of an individual patient. There are patients who should not be placed under anesthesia, and perhaps in those patients, unconventional methods of plaque and calculus reduction may be warranted. However, advances in anesthesia and monitoring equipment have allowed the risk to be much lower than in past years. Because the non-anesthetic options may not allow for diagnosis of chronic dental pain and infection, and because more evidence exists that maintaining a healthy mouth allows for maintenance of a healthy body, the benefit/risk ratio will be favorable in the vast majority of patients. David summed it up nicely when reflecting on his experiences as a pet owner who pursued NPDS. "General practitioners may not realize that pet owners want to believe ‘cleanings’ of any kind, if done regularly, are sufficient. What’s not to embrace about a method endorsed by your vet, which saves money, seems to be safer and seems to let you off the hook for routine home care?” To be fair, most veterinarians have not received appropriate training in veterinary school to know what a professional dental cleaning involves and that not all "cleanings” are of equal benefit. As schools of veterinary medicine supply more learning opportunities in the fundamentals of dentistry, clients and their pets will benefit from the knowledgeable advice their veterinarians can provide. Dr. Lewis, FADV, Dipl. AVDC, is assistant professor of dentistry and oral surgery at the University of Pennsylvania School of Veterinary Medicine in Philadelphia.
