Appendix U: Dental Scoring & Contesting
Promoting the Human-animal Bond in Veterinary Practice
Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives

Dental grades only are required for patients with teeth. Dr. Tom Cat


All knowledge and meaningful discussions start with calling things by their right name. When it comes to veterinary dentistry, there is not one set of nomenclature, so the general companion animal practice must establish what they will use as a standard.

Dental Formulae

Kittens have a deciduous dental formula that looks like this:

2(i3/3 c1/1 p3/2) = 26.

What that means is that on each side of the head, they have 3 upper and lower incisors, 1 upper and lower canine and 3 upper and 2 lower premolars. The lower case letters are used to signify that we are talking about deciduous teeth.

The permanent dental formula in cats is as follows:

2(I3/3 C1/1 P3/2 M1/1) = 30.

Each side of the head has 3 upper and lower incisors, 1 upper and lower canine, 3 upper and 2 lower premolars and 1 upper and lower molar. The capital letters indicate permanent dentition.

The dental formulas for puppies are:

2(i3/3 c1/1 p3/3) = 28

and the permanent dental formula in dogs is as follows:

2(I3/3 C1/1 P4/4 M2/3) = 42.

The table shows the approximate age (in weeks) of eruption for deciduous and permanent dentition in dogs and cats.

Approximate Eruption Times of Teeth in Weeks



























It is important to note that there are no deciduous first premolars or deciduous molars. Though the deciduous mandibular and maxillary fourth premolars in the dog and the cat look very much like the permanent first molars and function just like them, they give rise to the permanent fourth premolars.

Selling the Sizzle

If you remember some earlier discussions, advertisers do not sell circus tickets, they sell thrills and excitement. Optometrists do not sell glasses, they sell vision (and some sell fashion). They do not sell coal, they sell heating. In veterinary practice, most all clients are "feelers", so we must sell peace of mind to people who have emotions and feelings, which is not the science most veterinarians were trained to convey, but does give us the reason most of the staff selected a veterinary practice as a place to work.

The human-animal bond becomes stressed when "puppy kisses" get to the point where the smell will gag the family members. Brown teeth mean 'bad breath' from bacteria, which also are harming the body, and red gums mean 'pain'; to ignore these conditions means You Don't Care! Wanting to "restore puppy kisses" is a nice phrase to use when opening the discussion about dental care. Other terminology includes:

 Even the early bad breath (DG 1+ mouth of a risk level one young adult) will be shedding enough bacteria to cause a positive ERD® (Early Renal Damage test from Heska®) = kidney damage.

 The 'slight redness' the early DG 1+ mouth (risk level one young adult) will only get worse = more painful.

 The early dental cleaning "DG 1+ mouth (risk level one young adult)" is a much faster procedure, at a lower cost, than the late dental cleaning "DG 2+ mouth (risk level one young adult)".

We know that very few pet owners pursue the toothpaste route (look at the toothpaste refill rate). We must add excitement to the process, so we often ask practice staff members to participate in a "puppy kiss" contest. To start a contest, everyone must know the rules, and they are not difficult, but it requires a total commitment by everyone to "make it happen", here are the basics:

 Brown Teeth = Bad Breath and Red Gums = Pain......and the client needs to hear this loud and clear.......if their mouth looked like their pet's mouth, they would have No Friends.

 The CET brochure, and Smile Books, have four sequential pictures, from red gums (grade 1, +, or DG1+), to brown teeth without much plaque (grade 2, ++, or DG2+), to heavy plaque/tartar (grade 3, +++, or DG3+), to calculus/tartar and bone destruction (grade 4, ++++, or DG4+).

 The dental grade will be recorded during each visit, but only after looking at the previous grading level.

 In progressive practices, the dental grade will be followed by a box "[ ]". A box ([ ]) denotes a "need" was stated to the client. In cases of practices with electronic medical records, the box ([ ]) is not effective, since it is very hard to enter anything inside the box, so we use CR-__, as in Client Response-__.

 In a high communication practice, the entry in the box (need = [ ] or CR-__) is the client's response to the stated need: W = waiver (no way, don't believe in it, get out of my face, etc.), D = defer (maybe next time, let me think about that, I have to ask the family, etc.), A = appointment (later this month, maybe next week, after payday, etc.), or X = do it now!

 Every time a "need box" ([ ]) or "CR-__" has something besides an "X" in it, it will be followed by the provider's response: 3w = three weeks, 4m = four months, etc.

 Each encounter with a client/patient requires the next contact (called the three R's) be established before the client departs the practice, done today, without exception; Recall (phone), Remind (mail), or Recheck (come back in).

 The dental grade and three R expectation(s) are entered into the computer service code (recall) system during the invoicing process.

This sets the system for the next phases, which are internal promotions (targeted marketing). The AAHA dental tapes and Dental Smile Books are a good training aid if used by the entire healthcare delivery team, including but not limited to, doctors, nurses, dental hygiene technicians, client relations specialists, telephone receptionists, etc. Please remember three things: 1) effective internal promotions marketing starts with training, 2) is expanded as you listen to clients to hear the question behind the question, and 3) the first and most important practice client is the belief of the staff member.

As an example, with effective training, for the Recall or Recheck, either a "[D] 3w"or "[A] 3w" causes the same team and computer expectation, home care and weekly update calls by the attending nursing staff: a first week, morning and nightly garlic water (tuna water for cats) tooth rub for the dog -- they like the flavor; a second week using "baking soda in the garlic water" for the morning and nightly tooth rub -- to start the abrasion feeling; then a third week using "a cloth with the baking soda garlic water" for the morning and nightly tooth rub -- so they get used to a foreign body in their mouth. Then after the client does this "no cost" test, they are told to return (it has now been three weeks) for a courtesy dental hygiene consult with the dental hygiene technician who has been calling weekly and coaching the home care. The result is generally impressive; over a 50 percent (most practices are closer to 75 percent) request rate for the hospital to clean teeth with one of the weekly follow-up phone calls. By three weeks, most all clients are tired of playing with the mouth, so returning clients also have a high closure rate.

For the Remind (snail mail or e-mail, never text messaging when soliciting business), we must use the dental grade to establish the postcard narrative to remind the client where the discussions were during the last veterinary encounter, such as:

 DG1+ = "The last time you and White Fang were in, we talked about the red gums and pain -- please check and see if this is resolved. If not, please schedule a consult with our dental hygiene technician -- it is a courtesy visit this time because we are concerned about the potential pain as well as the bad breath."

 2+ = "The last time you and White Fang were in, we talked about the brown teeth and bad breath, with increasing pain concerns -- please check and see if these conditions are improving for getting worse. If not, please schedule a consult with our dental hygiene technician -- it is a courtesy visit this time because we are concerned about the bad breath and pain, as well as potential infections."

 3+ = "The last time you and White Fang were in, we talked about the bad tartar, the gum infection and the terrible breath -- please check and see if this has gotten worse. If you can, please schedule a consult with our dental hygiene technician -- it is a courtesy visit this time because we are concerned about the shortened life span when teeth get this bad as well as the bad breath and mouth pain."

 4+ = "The last time you and White Fang were in, we talked about the generalized infection and major health hazard caused by calculus build-up on the teeth -- please schedule a consult with our dental hygiene technician -- it is a courtesy visit this time because we are concerned about the shortened life span, complicating problems, worsening mouth pain, and terrible breath caused by this bad a mouth."

The narratives need to be tailored to the providers in your practice, because they need to match the discussion phrases of the consultation room as well as the dental hygiene nurse technicians, client relation specialists and phone receptionists. They are specific to your practice philosophy.

So "On with the Contesting"

The ability to make a new project fun is to be innovative. Many practices use "contesting" as a way to make "practice emphasis" a fun time for all. As reported in AAHA Trends "Featured Practice", this "contesting" concept has been used very effectively by Dr. Connie Moll at Midland Animal Clinic, Midland, Michigan.

The concept is simply to bring the staff's attention to bear on a program of interest, and share the reward of the effort. This has been called the GMP* by Michael LeBoeuf (Greatest Management Principle, a wonderful and easy reading paperback text); behavior rewarded is behavior that will be repeated. In the greater scheme of things, contesting does cost the practice some reward money, and the contest "prizes" require taxes to be paid on the awards. The flip side of this "expense" is the value-added benefit derived when the staff "buys" into the program and become promoters rather than observers.

Not all practices can use contesting effectively, it is participant dependent. When a bonus or productivity pay is awarded with an employer's comment that "this is costing me money", the positive effects are erased immediately. Contesting and productivity pay systems are based on exceeding realistic expectations. I say realistic expectations because to be effective, at least 60 percent of the staff needs to "win." This means the "program" stretch must be incremental, and smaller steps are required to allow repetitive successes.

Option: The simplest "contest" we have used is 40 dental cleaning cases completed in 30 consecutive days. This gets them the new dental base of their choice, selected from the pictures of three integrated systems posted in the staff area. In reality, 40 dental cleanings (at appropriate pricing since dental cleaning is a staff function) will drive between $5720 and $10,560, dependent on the number of DG1+ vs. DG2+ cases booked. This amount of new money, invested in a new dental base, rewards the previous effort and gives the staff a new piece of equipment for providing better healthcare. Everyone wins!

Option: During National Dental Month - Do Not Discount! It will cause you clients to wait until the next discount time, and that is detrimental to the patients. Offer courtesy dental hygiene consults with the nursing staff during National Dental Month. You could also offer a free Pet Insurance Policy (each week or for the month) from a drawing for all animals that had a dental cleaning during the month.

 Pet Insurance will be subtly marketed to all clients this way

 Pet Insurance is a tax deductible client gift

 Pet Insurance gives clients $100 back for a dentistry (in the future)

Option: If contesting seems an interesting concept for you practice, I offer the attached chart as a diagrammatic representation of a more complex contesting effort. The contest does not have to be dentals nor does the owner have to take a vacation, but these are the things that excited the practice that requested we develop the picture for them to follow. The choice is yours, share success or share mediocrity; the world will keep turning regardless.

Dental Contest Plan

(potential of $6000+ per month increased gross)

Dental Contest
Dental Contest


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Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives

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