Delivering dental care

By Heidi Lobprise, DVM, DAVDC

Doing dental procedures means you have to stock up on a potpourri of materials in the practice. Let's look at some "consumable" supplies that need regular replenishing, as well as some tools you can use from patient care to owner education.

Procedure materials

Charts
Most of your procedures include dental cleaning, examination, radiographs, and other treatments. Dental charts are essential for accurate medical and legal documentation of physical findings and therapy. Gone are the days when a simple sticker applied to a patient's medical records page was sufficient. Even with paper records, an entire page (or two) of a dental chart is needed to record all findings adequately. Most practice management information systems now are electronic, and even if you use a paper chart, it can be scanned and filed in the patient record. Several online electronic charts, including simple templates and other commercially available resources, can be utilized (Figure 1).

Polishing
You might not think something as simple as polishing the teeth could be controversial, but in human dentistry, there is concern the cumulative loss of enamel over a person's lifetime could be significant. With hygienists, proper scaling leaves a very smooth surface,¹ but veterinary patients may be left with rougher surfaces and have fewer procedures over their lifetimes, so polishing is still recommended.

When the soft prophy cup and adequate polishing paste are used on a low-speed handpiece, the foot is splayed to even reach under the gingival margin. Oscillating prophy angles can help avoid the entrapment of hair rotary units sometimes experience (Oh, that sound of Yorkie hair getting wrapped up in the polisher!). Individual units of polishing paste can be used, or a large container can be used for multiple procedures, with smaller amounts retrieved to avoid contamination (Figure 2).

Most pastes contain pumice (fine or medium), fluoride, and flavoring. You can get adventurous and order from human dental supply companies to get "fun" flavors used in pediatric dentistry (i.e. birthday cake flavor). Alternatively, you can go back to basics and purchase flour pumice (very fine, no flavors or fluoride) and make your paste for each patient, especially if doing any dental bonding or restorations.

Regional and local blocks
The local anesthetic agent most commonly used in veterinary dentistry is bupivacaine. While lidocaine works a bit faster (time to effect is 1-2 minutes compared to bupivacaine at 5-10 minutes), it does not last as long (duration 1-2 hours compared to bupivacaine 4 to 24 hours).² Mixing lidocaine with bupivacaine does not help speed up the time to take effect that much, and it decreases the duration, so this is generally not recommended. Get the blocks done early enough to be effective for the procedures—from extractions to periodontal therapy. Care should be taken to stay within the dose range, at 1 mg/kg for cats and 2 mg/kg for dogs.

While it is not labeled for use in dental blocks, the author has been using a liposomal-encapsulated bupivacaine product regularly, injecting a similar volume at the sites. You can even potentiate bupivacaine by adding an opioid or dexmedetomidine, which will increase the duration of effect.³

Hemorrhage control
The vascularity of the oral cavity has its good and bad aspects: good, because the vascularity helps with healing, but bad when you cannot get the bleeding under control. Good surgical techniques with the ligation of larger vessels certainly help, but many smaller vessels can make hemorrhage control a challenge. With adequate closure of extraction sites, bleeding usually resolves eventually, but assistance can help speed up the control. Some products include:

• Absorbable hemostatic gelatin sponges that can be cut or molded to a desired shape for extraction sites
• Flowable, plant-based, hemostatic gel that comes directly in contact with blood to ionically crosslink, producing a stable endogenous fibrin patch at the wound site
• Topical hemostatic aluminum chloride anhydrous solution is applied to the bleeding area with pressure on a cotton-tipped applicator.

Bone graft material⁴
Numerous biocompatible veterinary products can be used in extraction sites and even periodontal surgery to help support bone fill or formation at the site. Synthetic bioactive materials (ceramics or polymers) act as scaffolding and can contain substances that encourage osteoblast infiltration and proliferation (osteoconduction), though the material is not absorbed. Bone allografts (from same species) are often freeze-dried particulates, with demineralized products presumably exposing bone morphogenic proteins (BMP) that can be osteoinductive, allowing the differentiation of osteoprogenitor cells into osteoblasts. A newer technology has been introduced in a product that provides a scaffolding implant to stimulate tissue repair and remodeling, triggering the body to repair itself, mimicking a healthy extracellular matrix (ECM).⁵

Autografts (bone particles from the same individual) or osteogenic grafts can also be used but are not as common in veterinary medicine. Various growth factors, from bone morphogenic proteins (some recombinant) to platelet-derived growth factors and enamel matrix derivatives, are more common in human dentistry due to availability and costs.

Periodontal materials
While adequately cleaning tooth and root surfaces in a periodontal pocket is beneficial, materials placed after the cleaning help reduce pocket depth and improve oral health. While the use of systemic antibiotics in periodontal disease is seldom recommended, local application of antibiotics may be an appropriate choice for some patients.

Clindoral is a periodontal pocket filler containing two percent clindamycin hydrochloride in a biodegrading, mucoadhesive gel matrix that releases clindamycin over seven to 10 days after a single application. As the product warms to body temperature, it increases in viscosity two- to three-fold to form a soft, pliable matrix with the consistency of a thick jam.

In Doxirobe, doxycyline hyclate is provided in a two-syringe system requiring mixing before use. Syringe A contains the polymer delivery system-N-methyl-2-pyrrolidone and poly (DL-lactide). Syringe B contains the active ingredient-doxycycline hyclate.

Once mixed, the product is a flowable solution equivalent to 8.5 percent doxycycline activity. The formulation is applied subgingivally to the periodontal pockets of affected teeth, and doxycycline is slowly released from the polymer, providing a local antimicrobial effect, particularly toward gram-negative anaerobic bacteria involved in periodontal disease. The product is nonirritating and biodegradable and also has anti-collagenase action as a tetracycline class product, helping reduce gingival inflammation.⁶

A periodontal sealant may be considered after therapy, polishing, and irrigation. Options include a hydrophilic gingival dental sealant placed at the dried gingiva sulcus to act against plaque formation while allowing water and oxygen to pass into the sulcus, potentially effective for six months.⁷ All of these products should be evaluated based on the extent of disease, ability to effectively clean subgingivally, cost, and follow-up care.

Patient care

Appropriate medical care customized to each patient and procedure, though that discussion would be an entire subject on its own. Even all the products and methods of home care could fill another volume as another part of patient care.

For immediate post-operative care, particularly if oral surgery was performed, the patient may require an Elizabethan collar or similar device to help prevent self-trauma. Cool compresses can be used to reduce discomfort and inflammation, and that can be as simple as a small wet washcloth that has been frozen and then allowed to thaw and soften partially. You can recommend that the owner use a targeted PEMF (pulsed electromagnetic field) device to help decrease inflammation and pain.⁸ You can stock the devices or have owners get them online.

Various antioxidants, such as omega-3 fatty acids in fish oils and even esterified fatty acids (1-TDC), may benefit some patients with chronic inflammation from oral and dental disease.⁹ For any product recommendation, ensure reasonable data supports its use, that no harm is done, and that owners can utilize the product without stressing their pets.

Client communication

Client communication and education about the diseases, their treatment, and ongoing patient care play a significant role in oral health. Informative handouts, postings on your website, sharing photos, and reviewing the dental chart can all be beneficial.

Sometimes, they need more "proof" on initial examination that problems are present, so the quick detection test for thiols can help identify underlying active periodontal disease.⁹

Other "show and tell" tools can also be very helpful, including dental models and actual skulls (as long as you ask owners if you can use them) for demonstration.

It is helpful to have at least a dog skull, a cat skull, and a brachycephalic dog skull, what I consider to be the third "species" in small animal practice, as their anatomy can be quite different. You can use the skulls in practice to help take radiographs and do dental blocks. You can also get some modeling clay to recreate the presence of an oral mass to help the owner understand the extent of the lesion and the potential surgical margins (Figure 3).

Summary

There are many tools and products that can help you provide optimal dental care for your patients; this article is by no means a comprehensive list. While you cannot be familiar with everything, stay informed on items you can practically implement in your clinic.

Heidi Lobprise, DVM, DAVDC, is a 1983 Texas A&M University graduate. She became board-certified in dentistry in 1993. After 10 years in the industry, Dr. Lobprise returned to dental specialty practice in 2014 and has since "semi-retired" in Kerrville, Tex. Lobprise is the author/co-author of three dental texts along with many chapters and articles.

References

1. Pattison, A. M., Pattison, G. L. (2006) Scaling and root planing, in Carranza's Clinical Periodontology. Eds F. A. Carranza, M. G. Numan, H. H. Takai, & P. R. Klokkevold. WB Saunders,  St. Louis. pp 749-797.

2. Grubb T, Lobprise H. Local and regional anaesthesia in dogs and cats: Overview of concepts and drugs (Part 1). Vet Med Sci. 2020 May;6(2):209-217. Epub 2020 Jan 21. PMID: 31965742; PMCID: PMC7196681.

3. Snyder LB, Snyder CJ, Hetzel S. Effects of Buprenorphine Added to Bupivacaine Infraorbital Nerve Blocks on Isoflurane Minimum Alveolar Concentration Using a Model for Acute Dental/Oral Surgical Pain in Dogs. J Vet Dent. 2016 Jun;33(2):90-96. Epub 2016 Aug 6. PMID: 28326977.

4. Lobprise HB, Stepaniuk K. Oral Surgery – Periodontal Surgery. In Lobprise HB, Dodd TR eds, Wiggs' Veterinary Dentistry, Principles and Practice. Hoboken, NJ :Wiley-Blackwell, 2018: 193-228.

5. Gawor JP, Strøm P, Nemec A. Treatment of Naturally Occurring Periodontitis in Dogs With a New Bio-Absorbable Regenerative Matrix. Front Vet Sci. 2022 Jun 21;9:916171. PMID: 35799840; PMCID: PMC9253764.

6. Zetner K, Rothmueller G. Treatment of periodontal pockets with doxycycline in beagles. Vet Ther. 2002 Winter;3(4):441-52. PMID: 12584682.

7. Sitzman C. Evaluation of a hydrophilic gingival dental sealant in beagle dogs. J Vet Dent. 2013 Fall;30(3):150-5. PMID: 24371922.

8. Alvarez LX, McCue J, Lam NK, Askin G, Fox PR. Effect of Targeted Pulsed Electromagnetic Field Therapy on Canine Postoperative Hemilaminectomy: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial. J Am Anim Hosp Assoc. 2019 Mar/Apr;55(2):83-91. Epub 2019 Jan 17. PMID: 30776260.

9. Lopes Kubitza FM, Anthony JMG. Topical oral 1-tetradecanol complex in the treatment of periodontal diseases in cats. J Feline Med Surg. 2019 Dec;21(12):1141-1148. Epub 2019 Jan 17. PMID: 30652935; PMCID: PMC10814267.

10. Queck KE, Chapman A, Herzog LJ, Shell-Martin T, Burgess-Cassler A, McClure GD. Oral-Fluid Thiol-Detection Test Identifies Underlying Active Periodontal Disease Not Detected by the Visual Awake Examination. J Am Anim Hosp Assoc. 2018 May/Jun;54(3):132-137. Epub 2018 Mar 20. PMID: 29558213.