The Veterinary Dental Patient: A Multidisciplinary Approach. Группа авторов

appear to have problems drinking or swallowing?”

       “Has there been a change in the patient's habits or behavior? Do they rub their face on the carpet or paw at their face?” Face rubbing, apart from being a common signalment of allergy, can also be a sign of oral pain or inflammation.

      4.5.2 Oral Examination: The Conscious Patient

      A general health exam must be performed by the veterinarian. The entire animal should be examined, nose to tail. A thorough exam should include the eyes, ears, skin, heart, lung, and abdomen. If anesthesia is planned, it is highly recommended to perform blood and urine analysis.

In a well‐managed practice (i.e. one that effectively utilizes lay staff), the veterinary technician/nurse can perform the initial oral examinations on both the conscious and the anesthetized patient and report their findings to the veterinarian (Figure 4.8). The conscious exam is limited to olfactory, visual, and tactile examination.

      Is the head symmetrical? Do both sides appear to be uniform or does one look different to the other? (Niemiec 2010) Is there swelling in any area of the mouth/head? If swelling appears below the eye, look for a fractured maxillary fourth premolar. Do the jaws appear symmetrical? If one side of the jaw is swollen or asymmetrical, rule out mandibular or tooth fractures, or oral masses.

      Feel the head. Palpate the bones of the head, including the zygomatic arch and mandibles. Feel for the presence of abnormalities. Evaluate the lymph nodes, including the sublingual and submandibular nodes. Inflammation in the oral cavity can contribute to swelling of these nodes. The temporomandibular joint should also be palpated for indications of pain or discomfort.

      A detailed oral exam should be performed prior to anesthesia, if possible. Check for occlusion, tooth fractures, gingival recession, and inflammation, as well as missing, supernumerary, or loose teeth. Count the teeth. This task can be difficult as not every patient is willing to allow a complete examination, especially if they are head shy or young. Each tooth should be evaluated for fractures, mobility, and the amount of plaque and calculus present.

Figure 4.8 Concious animal assessment.

      While it is most important to evaluate the gingiva under general anesthesia when the gingival index and pocket depth can be evaluated, it is important too to observe the gingiva to determine a preliminary degree of periodontal inflammation. Healthy gingiva is pink with defined margins, while inflammation is indicated by red, swollen gums. Gingival recession or enlargement is a key element of periodontal disease and should be noted.

A complete examination can only be completed under general anesthesia, but examination of the conscious patient can yield vital information that can help create the initial treatment plan and client estimate (Figure 4.9).

      4.5.3 Treatment Plan

      Even the best veterinarian may not practice their dental skills if the owner does not give permission. The client needs to understand the pathology and the reason for therapy. The technician plays a vital role in providing this education.

      The treatment plan should be itemized and must be as accurate as possible. The technician should go through it with the client, explaining the reason for and value of each item. For example, preanesthetic blood work can sometimes locate systemic problems that have a bearing on the anesthesia protocol, as well as determining the patient's anesthetic risk. Dental radiographs are necessary to determine whether there is pathology that is not visible to the naked eye.

      Explaining the treatment plan line by line helps the client understand the need for and importance of the treatment. Clients can see and understand pathology more easily in pictures, models, and videos than directly in the oral cavity of their pet. The treatment plan should also address the patient's anesthetic risk level and explain the precautions necessary for a positive outcome.

      It is good practice to provide a treatment plan or estimate to the client prior to every procedure. This prevents distress over unexpected expenses and helps the client understand that the procedure is important to their pet's health. Providing an estimate in advance can also help the client make arrangements for payments.

An exact treatment plan cannot be determined on a conscious patient, but a close estimation can be created from the oral exam. The veterinary technician/nurse should explain that the treatment plan is only an estimate and that a more accurate one can be prepared once the animal is under anesthesia and a complete oral exam and dental radiographs have been performed.

Figure 4.9 Client estimate, prepared based on a filled‐in dental chart.

      Creating an estimate that is higher than anticipated can have a twofold benefit. First, it provides for an allowance if the periodontal disease turns out to be more advanced than is thought from the initial exam. Second, the client may be pleasantly surprised to receive a lower bill than expected. If the client would like a more precise estimate prior to the procedure, a “worst‐case scenario” can be prepared, but this should be properly explained to them.

      The veterinary technician/nurse should develop an understanding of the client's commitment and ability to perform home care, which will help develop the treatment plan (Bellows 1999). The veterinarian may thus plan to refer the patient to a dental specialist for periodontal surgery in order to save their teeth, or else to extract the teeth in the patient's best interest.

      4.5.4 Oral Examination: The Anesthetized Patient

Prior to the anesthetic procedure, the veterinary technician/nurse should ensure that the operatory is prepared and check all parts of the anesthetic machine and monitoring devices. As stated earlier, a thorough oral examination can only be completed under general anesthesia (Figure 4.10). The veterinarian and veterinary technician/nurse should work together to determine the best anesthetic protocol for the patient. The technician/nurse will prepare and administer the drugs for sedation and induction and perform preoxygenation prior to inducing and intubating the patient. They will then induce anesthesia with the assistance of the veterinary assistant or another veterinary technician/nurse. (In some countries, nurses are not allowed to induce anesthesia, so the veterinarian will have to do it themselves.) The technician/nurse must ensure the patient is correctly connected to monitors and that heating devices have been properly placed and the patient is at a surgical stage of anesthesia prior to beginning the oral examination.

Figure 4.10 Anaesthetised animal assessment.

      One of the most common reasons clients are resistant to dental procedures is the fear of anesthesia. It is important to explain that each patient will be fully evaluated and the best protocol will be used for their particular needs. It is also reassuring for the client to know that a dedicated anesthetist will be on hand during the entire procedure. The anesthetist will closely monitor the patient, ensure they are kept warm to prevent hypothermia, and keep detailed records of the anesthesia event.

      A veterinary technician/nurse who has received a decent amount of dental