I AM sure that many staff in veterinary practices have come across the “But Mr Jones down the road is only charging £Y for a dental. Why are you charging so much more?”
The frustration generated by this response to an attempt to organise a dental procedure stems from the knowledge that your practice has invested heavily in proper staff training, excellent equipment and facilities to ensure that a first class job is provided.
So why doesn’t the client appreciate all that you are trying to do?
The way to tackle this is to try and differentiate apples and pears – so that a proper comparison can be made.
It is perfectly reasonable for a client to wonder why a “dental” at practice A should cost so much more than a “dental” at practice B.
Some veterinary dentists prefer to use the term “professional teeth cleaning” – however, anyone and their auntie can claim to be a professional and it doesn’t really help to differentiate the level of service. For this reason the term “COHAT” is gaining in popularity in the United States.
COHAT is an acronym for Complete Oral Health Assessment and Treatment. This is now really getting to the crux of the matter – this is no longer a “dental”.
It is essential, however, that the term COHAT does not become devalued: if you are not following the whole process, then you should not mislead clients by using the term.
THE COHAT PROCESS History
- As with most veterinary investigations, things begin with the history. Has there been any evidence of oral pain? Is eating being performed normally? What is the pet’s diet, any recent changes or dietary preferences? Are pets generally well, or are there other existing disease conditions (e.g. diabetes) present? Has there been recent weight gain or loss? Even if the pet is presently fine, is there any history of problems in the past? What oral home care measures (e.g. daily toothbrushing) are presently in place?
- Where available, assessment of the records and radiographs from previous COHAT procedures can be invaluable. This will save repeating the radiographs of missing teeth for example.
Examination
- Patients are then examined from a distance (Figure 1), looking for signs of asymmetry (e.g. swellings on one side) around the face. We note whether the pet appears to have been grooming and look for any obvious signs of discharges or other problems.
- A general physical health check is carried out: an assessment for generalised malaise or fever; the general body condition is noted and any signs of other systemic diseases are looked for; the abdomen is palpated for any possible masses or signs of liver enlargement; the heart and lungs are checked, as with any pre-anaesthetic assessment.
- Where possible, an oral and facial examination is carried out. In some pets this can be quite detailed. In some species (such as rabbits) the shape of the oral cavity means that even seeing all of the teeth can be difficult. In some individuals (because of their general nature or because of oral pain) the examination may also be limited.
- An assessment of facial features – symmetry (Figure 2), swellings, changes affecting the eyes (proptosis, epiphora, discharges, nictitans protrusion, eso or exo-tropia), salivary drool, and assessment of masseter muscles.
- A general assessment of the extent of calculus and plaque deposition.
- A general assessment of the level of periodontal disease present – obvious gingival recession, tooth mobility, inflammation, bleeding, pain, etc.
- An assessment of obvious oral masses, swellings, or discharges.
- An assessment of any obvious tooth fractures.
- Noting any obvious tooth discolouration.
- An assessment of the superficial drainage lymph nodes.
- Where appropriate, pre-operative blood samples are taken and analysed. Some patients may need intravenous fluid therapy support, pain relief, occasionally antibiotic cover, nutritional support and preoxygenation prior to the anaesthetic being administered.
Anaesthesia
It is essential to emphasise that full dental examination can usually only be carried out in an anaesthetised veterinary patient. For example, it is impossible to probe periodontal pockets in a conscious cat or dog.
- Pre-medication, pain relief and general anaesthesia. Together with suitable vital signs monitoring, patient support (heating, intravenous fluids, ventilation) during the anaesthesia.
- Local anaesthesia as appropriate for the individual case.
- An endotracheal tube must be used, together with suitable throat packs (Figure 3); otherwise the airway is not sufficiently protected from ingress of debris and water during the procedure. Aspiration pneumonia is a high price to pay for short-cutting this safety measure.
Detailed oral examination
- Assessment of calculus and plaque indices.
- Assessment of gingivitis.
- Assessment of tooth mobility.
- Assessment of furcation exposure (loss of periodontal attachment, exposing the junction between tooth roots).
- Assessment of periodontal pocket depth by probing (Figure 4).
- Assessment of gingival hyperplasia.
- Assessment of periodontal attachment loss.
- Assessment of periodontal disease index.
- Assessment of any oral swellings.
- Assessment of any fractured teeth.
- Assessment of any worn teeth.
- Assessment of any potential resorptive lesions.
- Assessment of any missing teeth.
Radiography
Radiography has to be considered as an integral part of a proper dental examination.
The majority of a tooth’s structure is hidden below the gum line. The majority of dental pathology only becomes truly apparent with radiography.
Without radiographs, 50% of diagnoses will be missed. With radiographs, potentially some serious complications of extractions can be avoided.
Typically radiographs should include:
- Tooth resorption screen – for all cats having a dental procedure (Figure 5). A simple screen of two or three easy to obtain radiographs will give a 90% certainty of diagnoses of tooth resorptive (TR) lesions. Given the incidence of TRs and the pain they cause, we owe it to our patients to actively seek and treat this problem.
- Skull radiographs should be obtained for rabbit dentals (Figure 6). This allows a proper assessment of pathology and better prognostic guidance. Some exotic pet specialists recommend obtaining “full-rabbit” views to ensure that other pathologies which may have led to secondary dental disease are not missed.
- Full mouth radiographs are ideal – but certainly any areas suspicious of dental pathology should be radiographed.
- Extractions – both before and after views.
- If there are oral swellings or other concerns of neoplasia, then thoracic radiographs are warranted.
Treatment phase
- Disinfection of the mouth with chlorhexidine solution.
- Local nerve blocks/anaesthesia as required.
- Removal of gross calculus and plaque (Figure 7).
- Ultrasonic scaling of the teeth.
- Cleaning of the periodontal pockets.
- Periodontal surgery, or arrangements for referral as appropriate.
- Biopsies of masses or tissues as required.
- Dental extractions as required (Figure 8).
- Closure of surgical wounds and extraction sites.
- Endodontic treatments or arrangements for referral made as appropriate.
- Post-operative x-rays as required.
- Polishing teeth.
- Periodontal pocket irrigation.
Case note recording
- It is imperative to record your findings and treatments provided (Figure 9).
- Radiographs should be identified and stored with the case notes.
- A care plan and recommendations for future treatment should also be recorded.
Home care
- Further pain relief and medication.
- Establish suitable home-care regimes.
- Arrange follow-up assessments.
Conclusion
By training your team to think of the whole COHAT process, rather than simply of a “scale and polish” or a “dental”, it becomes easier to convey this message across to your clients. Clients will no longer think that “all dentals are the same” and will begin to appreciate the complexity and quality of the service and care you wish to provide.
