Below the surface of anesthesia-free dentistry
The American Veterinary Dental College is waging a campaign against anesthesia-free dentistry for dogs and cats, complete with a new website for pet owners and general practitioners.
At the same time, Pet Dental Services Inc., a national provider of anesthesia-free dentistry, is moving forward on a study with the working title “A comparison of oral examinations and dental cleanings in non-anesthetized and anesthetized dogs.”
The AVMA and American Animal Hospital Association recently stated that dental cleanings should be performed under anesthesia. According to the 2013 AAHA Dental Care Guidelines for Dogs and Cats, “General anesthesia with intubation is necessary to properly assess and treat the companion animal dental patient.”
Anesthesia-free dentistry is growing across the country, nevertheless, as many pet owners perceive a need for pet dental care but fear the risks of anesthesia—and as more general practitioners offer the service, generally via a third-party provider.
The 2004 AVDC position statement “Companion Animal Dental Scaling Without Anesthesia” states that the procedure is inappropriate for a number of reasons.
“Even slight head movement by the patient could result in injury to the oral tissues of the patient, and the operator may be bitten when the patient reacts,” according to the statement. Also, “access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient.”
According to the statement, inhalation anesthesia with intubation provides three advantages: “... the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examination and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.”
Also according to the statement, “A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient.”
The AVDC launched its website on anesthesia-free dentistry, www.avdc.org/AFD, about a year ago. The college collaborated on the site with the Academy of Veterinary Dentistry. The sections of the site are “The Facts,” “For Pet Owners,” and “For Veterinarians.”
Dr. Curt Coffman of Arizona Veterinary Dental Specialists, an AVDC board member, said providers of anesthesia-free cleanings are able to clean some parts of the mouth but cannot see or reach all the parts. The teeth look cleaner, he said, “but yet, there are other parts of the mouth that haven’t even been examined, let alone cleaned, and those parts can still be diseased.”
Effective in 2014, Dr. Coffman’s neighboring Nevada amended the state veterinary practice act to require that veterinary dentistry—including cleanings—be performed under anesthesia.
Dr. Coffman said clients need education about anesthesia. He said, “No matter what your dog and cat’s age or what your dog or cat’s condition, almost every pet can have anesthesia.”
The AVDC position statement does not address radiography, but Dr. Coffman noted that intraoral radiography allows for evaluation of the whole mouth above and below the gumline beyond what a veterinarian can see even in anesthetized patients. He noted that dogs and cats really do need to be asleep for radiography.
Pet Dental Services
Joshua Bazavilvazo, Pet Dental Services founder and chief executive officer, said a pilot study of his company’s 11-step procedure for anesthesia-free cleanings sparked the interest of many in the veterinary community.
The pilot study involved 12 dogs, and the follow-up study now in progress involves 60. The investigators on the current study include two veterinary dentists and two veterinary technician dental specialists. The hope is to complete the study by the summer.
“I know what we do is beneficial for the pet, and it is a viable medical procedure that can be proven,” Bazavilvazo said.
Many pet owners want anesthesia-free dentistry, Bazavilvazo said. He said they are considering factors such as preventive care, safety, expense, and convenience.
Pet Dental Services provides cleanings only under the supervision of veterinarians. Bazavilvazo considers anesthesia-free cleanings to be complementary to cleanings performed under anesthesia. He said, “At every single practice that we work in, the anesthetic dentals go up because we find so much pathology just during our oral examination, before the dental is even started.”
Anesthesia-free cleaning might be an option for a young dog with mild buildup. “Veterinarians say, ‘Well, you’re not quite ready for an anesthetic dental yet,’” Bazavilvazo said. “So we would fit in and be able to take care of the pet’s teeth as a preventive measure.”
In another scenario, a dog might undergo dental procedures under anesthesia to address pathologic changes, then an anesthesia-free cleaning six months later to remove buildup. Bazavilvazo said anesthesia-free cleanings also might be an option for pets that truly cannot go under anesthesia.
Pet Dental Services employees learn behavioral management techniques to enable them to clean pets’ teeth without anesthesia, Bazavilvazo said. After ruling out animals on which anesthesia-free dentistry cannot be performed because of behavior or pathologic lesions, employees are able to work with almost all dogs and about three-quarters of cats, he said.
Bazavilvazo believes veterinarians’ main concern with anesthesia-free cleanings is that there is no certification process for individuals performing these procedures. Plus, some providers of the service don’t work under the supervision of veterinarians, even though state practice acts generally define dental cleanings for cats and dogs as part of the practice of veterinary medicine.
AAHA and AVMA
Soon after the 2013 release of its dental guidelines, AAHA started requiring AAHA-accredited hospitals to anesthetize and intubate patients undergoing dental procedures, including dental cleanings.
“Cleaning a companion animal’s teeth without general anesthesia is considered unacceptable and below the standard of care,” according to the guidelines.
Dr. Heather Loenser, AAHA veterinary adviser for public and professional affairs, said anesthesia during dental procedures first allows for intubation to protect the airway. She said anesthesia also allows for thorough cleaning and for thorough evaluation of the oral cavity, including dental radiography.
“I think these points are very valid, and they resonate with veterinarians,” Dr. Loenser said.
Dr. Loenser believes that the biggest advance in veterinary dentistry recently has been an understanding of the importance of dental radiography. She said dental radiography has been a nonmandatory standard for AAHA-accredited hospitals since 2003.
In 2014, the AVMA House of Delegates approved adding the following statement to the AVMA policy on “Veterinary Dentistry”: “When procedures such as periodontal probing, intraoral radiography, dental scaling, and dental extraction are justified by the oral examination, they should be performed under anesthesia.”
The AVMA Council on Veterinary Service oversees the policy and has formed a subcommittee to investigate nonanesthetic dentistry. Dr. Christopher Gargamelli, a member of the subcommittee, believes the AVMA is unlikely to revise the policy before the regular five-year review unless scientific literature on the topic emerges.
After observing anesthesia-free dentistry, Dr. Gargamelli said that he personally can see a place for the service in veterinary practice but only under the supervision of a veterinarian and within a veterinarian-client-patient relationship as an addition to cleanings and radiography performed under anesthesia.
“Say you have a dental cleaning under anesthesia every one to two years. Some patients may need more dental care than that,” he said. “Having this nonanesthetic dentistry performed may be a good fit for that patient.”
Dr. John de Jong, chair of the AVMA Board of Directors and owner of Newton Animal Hospital in Newton, Massachusetts, offers anesthesia-free cleanings in his practice under contract with Animal Dental Care Inc., another national provider of the service.
Dr. de Jong was highly skeptical of the service until he saw a demonstration. All the dogs, including his two dogs, sat quietly as the company’s employees did a “very thorough and professional job,” he said.
He said, “For clients that refuse to have their pets undergo anesthesia or balk at the cost of a dentistry under anesthesia, I believe that a conscious dental cleaning can be a valuable adjunct to a complete and thorough oral health care plan.”
Dr. de Jong’s practice team tries to get clients to brush their animals’ teeth, but toothbrushing generally doesn’t happen. So when the veterinarians find tartar and plaque, they explain the options and costs to clients. If an animal obviously needs an extraction or further exploration, then an anesthesia-free cleaning is not an option.
Animal Dental Care refers to its procedure as preventive cleaning and assessment, Dr. de Jong noted, and the company still advocates for dental procedures and radiography under anesthesia.
Dr. de Jong considers anesthesia-free cleanings to be very successful at his hospital, and he has noticed the service growing across the country.
“I am hopeful that the AVMA and AAHA might consider changing their current positions on anesthesia-free dental cleanings,” Dr. de Jong said. “Like many other colleagues that I respect, I was willing to consider the possibility and clearly saw a place for these procedures.”
AVMA policy on anesthesia in veterinary dentistry
The following are the sections of the AVMA policy “Veterinary Dentistry” that cover anesthesia:
- When procedures such as periodontal probing, intraoral radiography, dental scaling, and dental extraction are justified by the oral examination, they should be performed under anesthesia.
- Sedatives, tranquilizers, anesthetics, or analgesics are commonly used during veterinary dental procedures to provide restraint and reduce animal pain and suffering. Visual or radiographic recognition of oral or dental pathology and accurate assessment of periodontal health by probing of pockets require sedation or anesthesia. An endotracheal tube is to be placed to protect the lungs from the water droplets generated during ultrasonic dental scaling or when a high-speed dental unit is used. Preoperative sedation, intra-operative local or regional analgesia and post-operative analgesics are used as indicated to reduce the dose of anesthetic agent required and ensure a smooth, pain-free recovery period. Federal law restricts such veterinary prescription drugs for use by, or on the order of, a licensed veterinarian to ensure their safe and effective use.
Related JAVMA content:
AVMA resources for National Pet Dental Health Month (Feb. 1, 2016)
True Prophylaxis (Jan. 15, 2016)
Policy says dental procedures should be done under anesthesia (Sept. 15, 2014)
New dental standard required for AAHA accreditation (Oct. 15, 2013)