VETERINARY PRACTICE GUIDELINES
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hospitals may want to perform the treatment plan during the first anesthetic event so everything is done at that procedure. Whichever way the hospital chooses, there must be a client communication plan in place so the client is involved and feels comfortable going forward with the proposed treatment plan. Perform the anesthetized portion of the dental evaluation
of charting, cleaning, and radiographs when abnormalities are seen on the awake exam (such plaque or tartar at the free gin- gival surface of the maxillary canines or fourth premolars) or at least on an annual basis starting at 1 yr of age for cats and small- to medium-breed dogs and at 2 yr of age for large-breed dogs. Details on the recommended frequency of examinations are discussed under Progress or Follow-Up Evaluation (below).
Planning the Dental Cleaning and Patient Evaluation Use well-monitored, inhalation anesthesia with cuffed intu-
bation when performing dental cleanings. Such techniques increase safety, reduce stress, decrease the chances of adverse sequelae (e.g., inhalation pneumonia), and are essential for thorough and efficient evaluation and treatment of the patient. Attempting to perform procedures on an awake patient that is struggling, under sedation, or injectable anesthesia reduces the ability to make an accurate diagnosis, does not allow adequate treatment, and increases stress and risks to the patient.
Prior to Anesthesia Preoperative evaluation includes a preanesthetic physical
examination. It is crucial to follow the most up-to-date rec- ommendations for preoperative laboratory testing based on the patient’s life stage and any existing disease. Preoperative care includes IV catheterization to facilitate administration of IV fluid therapy, preemptive pain management, and antibiot- ics (when indicated). Review the most up-to-date guidelines on anesthesia, antimicrobial use, fluid therapy, feline life stage, canine life stage, preventive healthcare, pain management, and referral for specific recommendations.17–25
Anesthesia General anesthesia with intubation is necessary to prop-
erly assess and treat the companion animal dental patient. It is essential that aspiration of water and debris by the patient is prevented through endotracheal intubation. Cleaning a com- panion animal’s teeth without general anesthesia is considered unacceptable and below the standard of care. Techniques such as necessary immobilization without discomfort, periodontal probing, intraoral radiology, and the removal of plaque and tar- tar above and below the gum line that ensure patient health and safety cannot be achieved without general anesthesia.26 During anesthesia, one trained person is dedicated to contin-
uously monitoring and recording vital parameters, such as body temperature, heart rate and rhythm, respiration, oxygen satura- tion via pulse oximetry, systemic blood pressure, and end-tidal
CO2 levels q 5 min (or more frequently if sudden changes are noted).27,28
IV fluid therapy is essential for circulatory main-
tenance. Customize the type and rate of fluids administered according to the patient’s needs.29,30 Prevention of hypothermia with warming devices is essential
because the patient may become wet, and dental procedures can be lengthy.31,32
Additionally, suction and packing the cau-
dal oral cavity with gauze can prevent aspiration and decrease hypothermia. If packing materials are used, steps must be taken to ensure there is no chance of the material being left behind following extubation. Regardless of whether packing is used, the last step prior to extubation is an examination of the caudal oral cavity to make certain no foreign material is left behind. Proper positioning of the patient by placing them in lateral recumbency can also help prevent aspiration. Provide safe immobilization of the head. If oral surgery is planned, the institution of an intraoral local anesthetic is warranted in conjunction with the general anes- thesia. This decreases the amount of general anesthetic needed and reduces the amount of systemic pain medication required postoperatively.1,27,33
Local anesthetic blocks can last up to 8
hr, and they decrease hypotension and hypoventilation caused with inhalant anesthetics by reducing the amount of gas needed to maintain a safe anesthetic plane.3,6,34,35
Dental Procedures The terms prophy, prophylaxis, and dental are often misused
in veterinary medicine. A professional dental cleaning is per- formed on a patient with plaque and calculus adhered to some of the teeth, but otherwise has an essentially healthy mouth or mild gingivitis only. The intent of dental cleaning is to prevent periodontitis. Patients with existing disease undergo periodon- tal therapy in addition to professional dental cleaning. Dental procedures must be performed by a licensed veterinarian, a credentialed technician, or a trained veterinary assistant under the supervision of a veterinarian in accordance with state or provincial practice acts. Practice acts vary from jurisdiction to jurisdiction, and the veterinarian must be familiar with those laws. Surgical extractions are to be performed only by trained, licensed veterinarians. All extractions need to have postextrac- tion, intraoral radiographs. All dental procedures need to be described properly (Table 1), and a consistent method should be used to record findings in the medical record (Table 5). Positioning and safety of the patient is important. Manually
stabilize the head and neck when forces are being applied in the mouth. Avoid using mouth gags because they can cause myalgia, neuralgia, and/or trauma to the temporomandibular joint. If a mouth gag is necessary, do not fully open the mouth or overextend the temporomandibular joint. Never use spring- loaded mouth gags. Do not overinflate the endotracheal tube. Always disconnect the endotracheal tube when repositioning the patient to prevent trauma to the trachea.
Trends magazine, April 2013
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