B. Niemiec, DVM, DAVDC, DEVDC, Fellow AVD
Veterinary Dental Specialties and Oral Surgery, Dentistry, San Diego, CA, USA
Marketing: Improving your practice with the WSAVA dental guidelines
Many veterinarians have not heard of the World Small Animal Veterinary Association; much less know they are members. The WSAVA is an association of associations, counting over 200,000 members and 100 associations. Therefore, if you are reading this, you are likely a member of the association and have access to all of the educational and promotional material on the website and any CE provided.
Why Are the Guidelines Important?
Dental disease is the most common problem in small animal medicine. There are rarely any outward clinical signs, however, these conditions do cause significant pain and infection. Further, these conditions create many local and systemic ramifications. Therefore, dental disease is significantly undertreated. Further dental education is sadly lacking in most veterinary curricula. The combination of all these issues allows numerous myths and misconceptions to remain. This includes the overuse of antibiotics and anesthesia free dentistry.
What Are the Dental Guidelines?
The committee includes not only Diplomates of the American and/or European Veterinary Dental Colleges from 5 continents but also specialists in anesthesia and analgesia as well as nutrition. Finally, there are two animal welfare advocates on the committee.
The guideless contain sections on oral pathology, anesthesia and pain management, as well as the universities’ role in improving dental education. Further is a section on the importance of and how to perform a proper oral exam, which includes instructions on the use of a free on line charting system. Step by step instructions with full color images detail the basics of dental prophylaxis, dental radiology and extraction. Minimal equipment recommendations are made for the various areas as well as a thorough review on dental homecare. While non-anesthesia dentistry is discouraged throughout the text, its inappropriateness is the subject of its own section. Finally, the animal welfare impact of untreated dental disease is introduced.
This document is tiered by the socioeconomic position of various countries, to improve the minimum standards of care in a realistic fashion while still promoting best practice. The authors have strived to create a document that is not only available world-wide for free, but also written in a very accessible way.
Why Is Promoting the Dental Department Important?
Oral disease is by far the most common problem in veterinary medicine and there are generally only subtle to no clinical signs. However, patients afflicted with dental disease are quite often painful despite the lack of clinical signs. In addition, these disease processes cause significant localized and systemic medical problems. Ignorance abounds regarding dentistry both in the general public as well as in the veterinary field. This results in most patients being under treated. Therefore, proper dental therapy is financially rewarding and good medicine.
Over the last decade or so, there has occurred a significant loss of traditional revenue streams due to many factors. Vaccine revenue has been markedly reduced by new studies. In addition, flea and heartworm prevention as well as other prescription revenue has been lost due to online prescriptions. Finally, increased reliance on the internet or other information decreases the client trips to the clinic.
How to Increase Dental Compliance and Revenue
Dental revenue can be improved in four distinct ways. However, they do not stand alone; all of them should be included in the marketing plan. In fact, they are synergistic, by increasing more than one, they positively affect each other, further improving gains.
1. The first and most cost-effective way to attain this goal is to increase the number of dental prophylaxis procedures performed.
a. Client education: This is best performed by enlightening the population about dental disease. This should come not only from the veterinarian, but the entire staff. This includes technicians and possibly most importantly, receptionists. By educating the veterinary staff, you educate the clients and provide more dentistry. This ideally is in person, but if time is an issue, handouts or qualified websites can be effective as well. There are can be in person, or via handouts and/or websites. Client educational videos are available at www.dogbeachvet.com/
b. Superior, new equipment: Once the marketing plan is underway and the days are full, superior equipment will speed procedures. A new drill, ultrasonic scaler, elevator, or curette can markedly cut down on surgical time and increase the number of procedures performed a day. If a practice can do one more procedure a day 5 days a week at an average of say $400 it will pay off $4,000 worth of equipment in a month. Moreover, this will result in shorted anesthetics.
c. Continuing education/training: By learning better techniques veterinarians and technicians can speed the dental procedures benefiting the practice and the staff. The staff can be more efficient, which will also allow for the possibility of additional procedures. Furthermore, this efficiency will decrease operator stain and stress. Finally, proper performance of dental procedures should result in less surgical trauma and superior patient care.
2. The next way to increase income is by increasing the per dental procedure charge. Increase the number of treatment options for the clients. This does not mean doing things like root canals, jaw fracture repair and major oral surgery since what most DVMs charge for these it is not efficient time usage. By spending that time doing office calls the practitioner will increase income with less stress. A more efficient way to do this is by offering superior “basic” care. This should include:
a. Dental radiology,
b. Periodontal pocket treatment
i. Closed root planning/subgingival scaling
ii. Perioceutic (Doxirobe/Clindoral)
a) Barrier sealants
b) Regional anesthesia
c) Proper pain management
d) Bonded sealants
All of these will greatly increase income without a significant investment of time or money. Practitioners, who have mastered the basics, can consider proceeding to composite restorations and periodontal flap surgeries.
1. Clinics can markedly improve their dental and income by improving their pre-operative testing protocol. Furthermore, perform the pre-operative testing the day the cleaning is recommended, this will help lock clients into the procedure.
a. Complete blood panel (renal, hepatic, CBC, T4)
c. Chest radiographs
i. HCM is often not ausculted
ii. Over 50% of patients over 6 have significant findings on chest films
2. Provide superior (and necessary!) post-operative treatment
a. Pain management: opiates, NSAIDs, local anesthetics (nerve blocks)
b. Homecare products such as tooth brushes, rinses, and dental diets
Specific Cases Where Income Can Be Increased
A. Persistent deciduous teeth are a very common problem in small animal patients, especially toy breeds. Most clinics will do this and charge for it, but in general they will way under charge and under treat. These are large teeth that are time consuming extractions. By keeping the teeth, the clients can understand why the extraction is expensive. In addition, proper pain medication and radiology will increase the fee to a reasonable level.
B. Fractured teeth with pulp exposure are a very common occurrence in veterinary medicine (approximately 10% of dogs have a broken tooth with pulp exposure). All teeth that are fractured with pulp exposure are either painful, infected, or both. Therefore, all teeth need to be treated via root canal therapy or extraction. This does “bother the dog” and therapy is critical. If a minor tooth, extraction is a viable option. If it is a major tooth and the client is to be referred for root canal therapy, the patient should be placed on pain medications and/or antibiotics and a minimum database performed.
C. Worn teeth with root canal exposure need to be treated with root canal therapy or extraction. Teeth without root canal involvement should be radiographed to ensure lack of endodontic infection and then treated with composite bonding if indicated.
D. Discolored (intrinsically stained) teeth. A study by Hale in 2001 reported that only 40% of discolored teeth have radiographic signs of endodontic disease. However, when physically examined, it was discovered that 93% of the teeth were in fact non-vital. Therefore all discolored teeth should be treated as dead and infected (root canal therapy or extraction).
E. Feline tooth resorptive lesions are reported to be present in up to 60% of all cats greater than 6 years of age. These are very painful lesions and require therapy. These are diagnosed with an explorer along the gingival margin. Full mouth dental radiographs are indicated when lesions are found as they will generally have additional lesions. These teeth need to be extracted.
F. Periapical abscess can be treated by root canal therapy or extraction. If electing to perform an extraction, remember that they are surgical procedures and should be charged as such. By calling it oral surgery it changes client perception of the procedure. Dental radiographs and pain management including local anesthetics should be administered.
G. Oral masses are incredibly common in small animal dentistry (especially dogs). All growths no matter how small and normal appearing should be sampled and submitted to the lab for histopathologic analysis. In my experience about 1% of these biopsies will turn out to be malignant and need additional therapy. In addition they should all be radiographed to evaluate for bony involvement. This will help the pathologist to determine level of aggressiveness.
H. Uncomplicated crown fractures are a very common finding in large breed dogs (at least 50%). This occurs when a piece of the crown is broken, which exposed the dentin, but not the root canal. Occasionally, these teeth can become infected through the dentinal tubules which will go undiagnosed without dental radiology. However, teeth with no to small pulpal exposures tend to be the ones with clinical abscessation. Even if these are not infected, they are at least transiently sensitive and require restoration.
b. Dental radiographs are WNL
i. Bonded sealant
ii. Recheck radiographs in 9–12 months
c. Radiographic evidence of endodontic disease
i. Root canal therapy
Key Points of Periodontal Disease from the DG
- Periodontal disease is by far the most common medical condition in small animal veterinary patients.
- Plaque forms within 24 hours, calculus within 3 days and gingivitis begins as early as 2 weeks.
- Periodontal inflammation is caused by subgingival plaque; therefore, control of plaque needs to address both supra- and more importantly subgingival plaque to be effective at controlling disease.
- Calculus (or tartar) is essentially non-pathogenic.
- The first sign of periodontal disease is bleeding on probing or brushing which occurs prior to a color change.
- Periodontal infections have been linked to numerous systemic maladies including:
- Diabetes mellitus.
- Heart, lung, liver, and kidney disease.
- Early mortality.
- Periodontal disease has been associated with numerous severe local effects including:
- Oronasal fistulas.
- Oral cancer.
- Mandibular fractures.
- Ocular infection and blindness.
- Osteomyelitis and osteonecrosis.
- Class II perio-endo lesions.
Key Points of Periodontal Therapy from the DG
- A professional dental cleaning is an involved procedure with numerous steps.
- All periodontal therapeutic procedures must be performed under general anesthesia.
- Each step must be properly performed to achieve a positive outcome.
- Sufficient time must be allotted for the procedure to have significant clinical benefit.
- Subgingival scaling is the most important step of a professional dental cleaning.
- A complete oral exam and charting is a critical part of the procedure.
- Daily homecare is recommended since plaque accumulates in 24 hours.
- Without homecare, the efficacy of professional periodontal therapy is severely limited.
- Tooth brushing is the gold standard and is most effective on rostral teeth.
- Passive homecare methods may or may not be effective, and any provided benefit will be mainly on the caudal teeth.
- Standard dry dog food is not beneficial for oral health.
How Will Members Benefit from the DG?
The sections on oral pathology provide current diagnostic and treatment recommendations for common oral pathology. The text is supported by numerous full color pictures as well as dental radiographs. Since this is available on line for free, it can facilitate client communication. This will improve dental compliance, thus improving patient care and practice income.
The anesthesia and analgesia section contains instructions and recommendations for pre-anesthesia testing, drugs, and monitoring. This is the latest information and is a valuable resource for the practitioner. Further, this section details the most current level of safety, which should further increase compliance.
The numerous mentions of the inappropriateness of NAD will greatly aid practices in decreasing this wholly ineffective practice. The arguments against this procedure are presented in not only the dental prophylaxis section, but also in the anesthesia and welfare areas. This combination, together with a listing of all the professional associations who oppose it will aid in client discussions.
Finally, but perhaps most importantly, is the section on the welfare aspect of untreated dental disease in small animal medicine. This well referenced section, penned by non-dentists, highlights the plight that our pets face on a daily basis when dealing with untreated dental conditions. By using the term “animal welfare concern” we can improve the acceptance of recommendations on a personal as well as association level. Together we can strive to improve oral care for pets worldwide.