1. Veterinary dental nursing procedures
PATIENT ADMISSION & DISCHARGE

2. Patient Admission Prior consultation with vet? Gather records
Decide on allowed delay between last visit and admission by nurse (without vet)
Gather records
Mostly computerised nowadays
Maybe radiographs, pathology, referral
Admission protocols may vary widely between veterinary practices
Take history
If new client > have a veterinary consultation first
Gather records
Previous relevant ancillary records such as radiographs, pathology results
Referral letter if referred from another practice
Dental procedures may be routine or non routine.
Routine procedures:
Descaling (dental prophylaxis)
Polishing teeth
May be performed on an animal of any age.
Non routine:
Treating periodontal disease. Frequently performed on patients that may have been unable to obtain adequate nutrition due to pain and discomfort; or geriatric animals.
Obtain authorization:
Ensure owner has a full understanding of the procedures likely to be performed. Make it clear that general anaesthesia will be required. Mention the possibility of gingival surgery, root planing, radiographs and extractions.
Authorisation form as for routine anaesthesia and surgery
Authorisation for pathology profiles if required
With compromised or geriatric patients assess liver and kidney function as patients with periodontal disease may have the added complication of a chronic bacterial infection.:
blood count
biochemistry profile
urinalysis
Also make note of:
When the patient last ate or drank
When the patient last urinated and defecated
Any changes since the last dental examination
Current home dental hygiene regime (of the patient)
Any current medication
What type of food the patient usually eats
Patient weight (for accurate administration of medication, anaesthetic and fluid therapy)
Obtain a contact telephone number for the day, as estimating costs for dental procedures is often difficult and the owner may wish to be informed before any surgery is carried out. Dental procedures may also be quite time consuming and the owner may need to be contacted and advised of an appropriate discharge time for the patient.
The owner also needs to be advised of an appropriate time to contact the clinic for a progress report. The owner should be aware that dental procedures are classed as 'dirty' or 'contaminated' surgeries and are often performed at the end of the surgical list.
Depending on practice policy the owner may be required to complete a 'consent to perform surgery' form. This is an important part of the admission procedure and also provides a safeguard against litigation.
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3. Routine vs Non-routine Dental
Descaling
Polishing teeth
Gingivitis
Non-routine
Periodontitis
Extractions required
Endodontics required
Aged animals
dental prophylaxis ‘prophy’
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4. Authorisation
Ensure owner has a full understanding of the procedures likely to be performed. Make it clear that general anaesthesia will be required.
Mention the possibility of gingival surgery, root planing, radiographs and extractions.
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5. Authorisation
Authorisation form as for routine anaesthesia and surgery
May also require authorisation for
Pathology
Radiography
Surgery
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6. È Owner Contact Contact phone number/s required
To advise of unexpected procedures/costs during dental
To advise of discharge time
Obtain a contact telephone number for the day, as estimating costs for dental procedures is often difficult and the owner may wish to be informed before any surgery is carried out. Dental procedures may also be quite time consuming and the owner may need to be contacted and advised of an appropriate discharge time for the patient.
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7. Before Patient Discharge
The patient must be
Clean
Dry
Odour free
Discharge of animals*
The patient must be:
Clean
Dry
Odour free
It may be the responsibility of the veterinary nurse to discharge the dental patient. As with any surgery it is preferable (although not always practical) to set aside an appointment time to allow the nurse adequate time to explain the procedure and give the owner an opportunity to ask questions. Communication can often be difficult in a busy waiting room so when possible the owner should be escorted to a consultation room. Instructions should be given before the patient is returned to the owner.
Discharge instructions include:
An explanation of the procedures performed:
Visual aids:
dental charts
plastic models of dog and cat mouths.
Sutures:
Usually dissolving sutures are used - do not require removal
Check with veterinarian
Medications: ensure the owner understands treatment regimes for post operative medications:
Antibiotics
Analgesics
Other medications
Post-dental prophylaxis (see below)
Demonstrate brushing or rinsing
Can start gentle brushing one week after gingival surgery
Post-dental diet
Soft food for 1 week
Meat strips may be better than canned or dry food
Post dental oral cleansing:
Daily rinsing for 2 weeks with chlorhexidine 0.2% may be suggested
Removes food debris from sockets/sutures and reduces bacteria
Follow up appointments:
Once a patient has undergone a dental procedure or is known to be at risk from dental disease it is advisable to have regular check ups to check for evidence of recurring disease. Also it is important to offer the owner advice and encouragement with their dental home care routine.
Post-op especially if oral surgery such as extractions, gingival flaps
Long term follow up dental checks (will vary with hospital policy): for example:
If healthy mouth > 12 mth check
If early periodontitis > 6 mth check
If severe periodontitis > 3 mth check
Collect fees or issue an account
Return the patient to the owner
Dietary recommendations*
Foods predisposing to plaque:
Canned food
Semi-moist food
Foods resisting plaque:
Raw bones
Effective chewing:
Mechanically cleans tooth surfaces
Stimulates flow of saliva (saliva is also good)
Maintains muscle tone and strengthens jaw bones
Toughens gums
If dog can tolerate this kind of food
Not all dogs chew however
May not clean the cuspid (canine) teeth
E.g. beef/mutton bones for dogs; young bones veal/lamb are softer and less likely to cause problems
Chicken necks/wings, small oxtails for cats and very small dogs
Fresh, raw, not too fatty
Not sun-dried, cooked or smoked. Not cow hooves either.
Remove after 10 mins?
Hard bones > possible tooth injury (esp fractured carnassial teeth), gastritis, obstruction, perforation, constipation etc
Commercial dental diets (e.g. Hills t/d)
Has larger pieces – harder and less brittle due to aligned fibres
Abrades tooth surface to scrape off plaque
HMP (hexametaphosphate) traps calcium to reduce calculus formation
Owner dental prophylaxis recommendation*
Note: often the term dental prophylaxis is also used to describe the process of dental scaling and polishing as well as describing the dietary measures to prevent plaque and calculus accumulation.
Dental home care refers to the procedures that clients use to aid prevention of dental disease in their pets. Primarily this includes foodstuffs, chews, toys and brushing which mechanically controls the build up of dental plaque or antimicrobials or enzymatic agents which chemically control plaque build up. This coupled with regular veterinary examinations to assess oral health will determine the frequency of dental treatment that the patient needs.
The clinic may provide displays or leaflets educating clients about the signs and dangers of periodontal disease and also provide advice on prevention. The veterinary nurse should be aware of the full range of products that are available and how to use/apply them.
Each owner and their pet generally needs to have their dental prophylaxis regime tailored.
Staple foods
The physical consistency of food does have an effect on a patient's oral health.
Commercial pet foods are often blamed for the decline in our pet's oral health, however the natural diet of bones, meat and fibrous material can also damage teeth, causing them to fracture and break off.
Dried food is often recommended as the chewing action exercises the gums and reduces the accumulation of plaque and calculus.
A prescription diet is available for dogs and cats which uses an oversize kibble that contains fibre strands. As the dog or cats teeth penetrate the kibble, it does not shatter so the food wipes along the tooth surface cleaning as it goes
Raw meaty bones
The feeding of uncooked chicken necks and chicken wings to cats may be beneficial, as this promotes the chewing action. Unless they have been introduced to such foods from an early age many cats, however, refuse to eat these. Many larger dogs also enjoy marrow bones and this promotes the use of the molars and premolars. However feeding bones may lead to constipation or obstruction due to a piece of bone breaking off. Always consult the veterinary surgeon before advising the feeding of bones.
Brushing
The advantage of brushing your pet's teeth is its effectiveness and affordability. However, to the patient, these are not priorities and resistance is often met. Also, if an incorrect technique is used, the owner may damage the gums.
Useful if owners can manage this daily. Consider demonstration of technique to owners:
Familiarisation: Effective brushing begins with teaching the owner correct handling techniques, behaviour training and positive reinforcement. The training should begin with the animal and owner in a relaxed environment. Initially the owner should begin by handling the animal's head. This includes opening the mouth, lifting the lips and rubbing the teeth and gums with their finger. When the animal accepts this practice, the owner can then begin to rub the teeth and gums with gauze, sponges or finger brushes. A toothbrush can be introduced to this routine only when the patient is compliant. Start slowly, animal in a relaxed state
Practice handling the mouth for a few days
Initially use your finger in a tooth brushing role, add flavours like meat broth or tuna water
After a week or so start using a toothbrush soaked in flavourings (above)
Slowly increase the number of teeth cleaned and the duration of the exercise
Generally one need only clean the outsides (labial aspects) of the teeth
Use ample praise
Show how to hold muzzle without causing injury to pet (or owner)
Brush type: The design of the head and handle of the toothbrush and the softness of the bristles will influence the effectiveness of dental hygiene. It may be necessary to try different products to find a suitable one for each animal. Can use:
finger-mounted brushes
soft (eg children’s) toothbrush
swab/cloth
Brushing technique: Generally, the bristles should be placed at a 45° angle to the gingiva and gentle circular strokes are applied, working from the gum line, to the top of the tooth.
Dental model: demonstrate on a dental model – before the animal is brought out to owner, then ask owner to repeat the demonstrated techniques
Toothpaste: May use any pet flavoured dentifrice (powder or gel). Palatability may increase chances of patient. Human toothpaste can cause problems from high fluoride and detergents (e.g. gastritis). 'Human' toothpastes are designed to be expectorated (spit out), a technique which few animals have mastered!
Ideally would brush daily but even every 2-3 days would be of benefit
It may be necessary to arrange a follow up appointment for demonstration of tooth brushing techniques, as many animals may feel uncomfortable at time of discharge.
Mouth rinses/sprays/gels
These products take the form of gels, which must be applied directly to the teeth and gums, sprays that are sprayed directly onto the teeth and gums, and rinses, which rely on contact with the teeth and gums in order to work. All of these products either contain enzymes, antiviral, antifungal or antibacterial agents that kill the pathogens which cause dental plaque.
80% of plaque is comprised of bacteria, which causes dental decay and odour.
Rinses and gels:
May help by reducing bacteria and encouraging healing of tissues.
May contain:
Chlorhexidine gel/liquid – good broad spectrum anti-bacterial but unpleasant taste, may stain teeth and promote calculus
Zinc ascorbate gel – anti-plaque properties (eg “Maxiguard ®”)
Pyrophosphates – Calcium chelators to reduce calculus, but not plaque
Hydrogen peroxide – antibacterial but potentially toxic to gingiva
If cannot perform brushing
Natural chews
There are a number of commercial pet chews that are designed to improve dental hygiene.
Some are similar to rawhide chews but are laced with enzymes that help to reduce plaque. Others are designed to promote gnawing and grinding in order to break down the chew, thus increasing exercise for the gums.
Other chews such as rawhide bones and pig's ears also provide exercise for the gums, however they should be used under supervision, as some animals will choke on them.
Rawhide bones
Pigs ears
Toy chews
Toys, which promote chewing, can assist with oral hygiene especially in dogs. Some plastic or rubber chew toys are designed with dental hygiene in mind, as their shape and texture increase abrasion against the tooth surface, cleaning the teeth. Poor quality rubber or plastic may be chewed into smaller pieces and swallowed, or shatter and damage the gums. If the material is too hard, it may break the teeth.
Dental toys:
Flavoured nylon bones
Rubber toys
Rope toys. Cotton rope toys help and many dogs enjoy chewing them. Nylon or polyester filament rope toys are designed to floss the teeth, although this isn't always necessary and care should be taken not to damage the gums. Can also cause problems sometimes. When advising the use of any of these products you should always be sure to choose good quality materials, the correct toy for the size and age of the patient and encourage supervision.
Compliance
The level of owner and patient compliance will determine which oral hygiene method you recommend. In all cases, the veterinary nurse should make sure that the owner is aware of advantages, disadvantages and safety considerations with each method.
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8. Discharge Instructions
Sometimes by nurse (if has been routine)
Make a time?
Consult room
Explain procedures performed
Explain diet, brushing, dentrifices
Medications
Sutures
Follow up appointments
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9. Patient Discharge
Best to bring out animal only after discharge instructions have been given
So owner not distracted by reunion with pet
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10. Explaining Procedures
Use models of teeth
Maybe show patients’s dental chart
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11. Sutures Usually dissolving sutures are used So don’t require removal
But check with veterinarian anyway
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12. Medication Ensure the owner understands use: Antibiotics Analgesics
Other
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13. Post-dental diet Soft food for 1 week
Meat strips may be better than canned or dry food
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14. Brushing Is beneficial if tolerated
Ideally daily (as for people)
Every 2-3 days also helps
Can start gentle brushing one week after gingival surgery
Reward for compliance
Plenty of praise
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15. Tooth brush
Must be soft
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16. Pet Toothpaste
Safe to swallow
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17. Brushing technique Relaxed environment
Initially handling head a mouth only
Then ‘finger brushing’ with meat broth/tuna fluid
Several days toothpaste on teeth only
Impress toothpaste into bristles
Hold mouth closed
Brush in circular pattern
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18. Brushing technique Gum line most important
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19. Oral antiseptics Chlorhexidine gel twice daily For first week
Applied to a gauze pad then wiped into each side of mouth
These products take the form of gels, which must be applied directly to the teeth and gums, sprays that are sprayed directly onto the teeth and gums, and rinses, which rely on contact with the teeth and gums in order to work. All of these products either contain enzymes, antiviral, antifungal or antibacterial agents that kill the pathogens which cause dental plaque.
80% of plaque is comprised of bacteria, which causes dental decay and odour.
Rinses and gels:
May help by reducing bacteria and encouraging healing of tissues.
May contain:
Chlorhexidine gel/liquid – good broad spectrum anti-bacterial but unpleasant taste, may stain teeth and promote calculus
Zinc ascorbate gel – anti-plaque properties (eg “Maxiguard ®”)
Pyrophosphates – Calcium chelators to reduce calculus, but not plaque
Hydrogen peroxide – antibacterial but potentially toxic to gingiva
If cannot perform brushing
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20. Other oral treatments Maxiguard® Zn as an antibacterial, may heal gums
MaxiGuard: Here's a terrific product that kills the bacteria, keeps the breath smelling sweet, and can actually help heal the gum tissue. You still have to keep after the plaque, though. It's called MaxiGuard, and it's available through your veterinarian. MaxiGuard comes in two forms: a spray and a gel.
MaxiGuard contains zinc ascorbate plus the amino acid cysteine. Sulfamino acid potentiates the zinc to make it kill bacteria. It does this by rupturing the bacteria's cell membrane. Zinc also helps heal the gum tissues, revitalizing the lost collagen component in them. It also breaks down bacteria that creates mouth odors. Of course, unless you brush, the odors will come back again, because the thing that caused the odor (plaque) is still there.
The product contains vitamin C powder, which must be mixed into the spray or gel to activate it. (Your vet may do that for you.) The spray should be refrigerated to keep it fresh, and does have a bit of a "vitamin C" tang to it that your pet may not appreciate when you spritz a little in his mouth.
The gel has no taste, so is a little more readily accepted by dogs. (And the spray noise won't scare them.) You can just put a little gel on your finger and rub it along the gums, so it's easy to use. (The manufacturer only sells through veterinarians, who can call (816) to find out where to order it.)
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21. Follow-up appointments
Regular check ups to check for recurrence
If healthy mouth > 12 mth check
If early periodontitis > 6 mth check
If severe periodontitis > 3 mth check
Encourage & advise owner
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22. Commercial diet 5888H - Veterinary Dental Nursing
Hills Prescription Diet Feline t/d is a complete and balanced dry diet for adult cats. The kibbles have a specially developed fibre matrix that resists crumbling as the tooth penetrates, providing a gentle scrubbing and cleaning of the tooth surface as the cat eats. Feline t/d reduces the rate of plaque, stain and tartar (calculus) accumulation on the teeth of adult cats. For maximum benefit Feline t/d should be fed to cats as a sole diet in conjunction with a veterinary supervised oral hygiene regimen. Not to be used in kittens, pregnant cats and in cases of severe periodontal disease. Presentation: 1.8kg and 4.5kg bags.
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23. Chew Toys
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24. Other dentrifices 5888H - Veterinary Dental Nursing
Virbac CT Chews have been designed to assist dogs with their dental hygeine by combining an antibacterial action with a mechanical polishing action. Regular chewing of this product will help keep teeth clean and gums healthy. Available in cat (24 chews) and small/medium and large dog packs, in 141g (approx 10 chews) and 454g (approx chews). Ingredients: Glucose oxidase, lactoperoxidase, potassium thiocyanate, beefhide, sea salt, chicken flavour, dextrose, vegetable proteins and primary dried yeast. Protein 7%; Fat 2.5%; Fibre 2.5%; Moisture 22%.
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25. Other dentrifices First ones under supervision Can choke
Can even break teeth on some
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28. S
Em dog
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29. Raw Meaty Bones
Some dogs may never require dental work if they eat a diet containing foods that clean teeth
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30. ‘Raw Meaty Bones’ - Dogs
Puppies
Minced chicken carcases
Adults
Whole carcases: rats, mice, rabbits, chickens, quail, fish
Meaty bones: sheep, goat, calf, deer, kangaroo
Miscellaneous: pigs’ trotters, pigs’ heads, sheep heads, brisket, tail bones, rib bones, fish heads, chicken heads, feet, necks, wings, carcases (meat removed)
Offal: liver, lung, trachea, heart, omasum, tripe
Table scraps: grate or liquidise veges, not cooked bones
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31. Owner education Start early at puppy preschool / kitten kindy
Importance of handling mouth area
Use client handouts/ sample T/D etc
Pet may require professional cleaning every 6 –18 months like human regular dental visits
Explain that periodontal disease can compromise general health due to circulating bacteria eg kidney, liver, heart disease
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