Open Wide

By Graham Garrison
December, 2017
When veterinary practices buy-in to dental care, opportunities abound for increased revenue and improved patient care

Jennifer Mathis, DVM, is something of a convert. Like many, she graduated veterinary school with a very limited knowledge of dental care, simply because it wasn’t emphasized in school. When she started practicing, she found dental cases and procedures a little intimidating.

“I hated dentistry,” she says. “Why would you want to do this stuff? It was awful. It was like pulling teeth.”

It wasn’t until 2009 when her perspective changed. A colleague showed her dental radiographs and taught her how to do proper extractions. “Having the right tools, it became fun, rewarding. I saw that I could make a big difference in patient’s lives.”

Indeed, Dr. Mathis doesn’t just practice dentistry now – she advocates for it as a speaker, and helps nearby practices get set up. She’s even studying to specialize in it. Dentistry has become a passion.

It’s also become a major source of revenue for her practice. “Within a year of really practicing dentistry, it became 30 percent of my practice revenue.”

Common, and preventable
Periodontal disease is the most common clinical condition occurring in adult dogs and cats, according to the American Veterinary Dental College. By three years of age, most dogs and cats have some evidence of periodontal disease. Dr. Mathis says that it is common for three out of every four patients a veterinary practice sees in their exam rooms to have oral issues. And most dental problems are preventable.

Vet-Advantage December Companion 2017 - Open Wide, Jennifer Mathis, DVM“When we do more anesthetic dental procedures, our patients are healthier,” she says. “Multiple studies show that patients are healthier. They have less kidney problems. Patients with diabetes require less insulin. Patients have less inflammation in the body and less incidence of disease. A healthy mouth is a healthy patient.”

According to the AVDC, periodontal disease begins when bacteria in the mouth form plaque that sticks to the surface of the teeth. Subsequently, minerals in the saliva harden the plaque into dental calculus (tartar), which is firmly attached to the teeth. Tartar above the gum line is obvious to many owners, but is not of itself the cause of disease. 

The real problem develops as plaque and calculus spread under the gum line, the AVDC says. “Bacteria in this ‘sub-gingival’ plaque set in motion a cycle of damage to the supporting tissues around the tooth, eventually leading to loss of the tooth. Bacteria under the gum line secrete toxins, which contribute to the tissue damage if untreated. These bacteria also stimulate the animal’s immune system. The initial changes cause white blood cells and inflammatory chemical signals to move into the periodontal space (between the gum or bone and the tooth). The function of the white blood cells is to destroy the bacterial invaders, but chemicals released by the overwhelmed white blood cells cause damage to the supporting tissues of the tooth. Instead of helping the problem, the patient’s own protective system actually worsens the disease when there is severe build-up of plaque and tartar.”

Dr. Mathis says patients with periodontal disease often suffer in silence. “Three out of four patients are affected? They’re not showing it most of the time, yet it is there, hidden.” she says. Owners often observe that their pet acts “years younger” following dental treatment.

Patients with other diseases – eye issues, nose issues – may well have dental problems hiding under the gum line that you don’t see, Dr. Mathis says. “They’re hidden, they’re suffering and we don’t know it. When you treat them, they are just happier. Brighter. Clients will tell us ‘I can’t believe how much more puppy-like our Fluffy is … I didn’t know he was having problems.’”

Getting up to speed
But to treat periodontal disease, veterinary practices need the necessary equipment to make the right diagnosis. Dr. Mathis says the turning point for effectively treating and preventing periodontal disease came when she invested in digital radiography for her practice. “Dental radiography equipment made a difference in the practice,” she says. “You have to take radiographs to see what you’re missing. You’re only looking at about a third of each tooth on the surface. Two-thirds is underneath the gum line. Until you take the radiographs, you don’t know. With radiographs, you’ll do more dentistry and have better patient care because you’ll find disease and be able to see what you are treating.”

Cost of the equipment may be an issue, but Dr. Mathis says she can make a pretty compelling case with colleagues on how quickly they would recoup the money spent. If you do two dental procedures a week, and charge for just what you find afterwards, you’ll pay for your equipment in six months, if not sooner, she says. “Even if you gave away the X-rays for free.”

However, unlike some veterinary equipment, dental radiography isn’t as simple as plug and play.

Danielle Heberle, dental clinical manager at Midmark, says most clinics have invested in a piece of equipment at one time or another that has not been utilized and therefore not provided a return on investment for the practice. “The reason this happens is lack of training and education on the product itself, clinical education, team training and client education training,” she says. “With training, most clinics can recoup their investment in 8-12 months. Dentistry can be the most profitable service offered in a practice and have a huge impact on the quality of patient care provided.”

Another challenge is if the practice makes an investment in dental radiography and high-speed delivery, how will they be trained? “A big concern is knowing how to identify disease and furthermore, how will they treat it?” Heberle says. “Because this was not taught in veterinary school this is a fear and something they do really need to understand before jumping in.”

There are three basic steps toward getting started, according to Dr. Mathis:

  • Buy/install the equipment
  • Learn to take images
  • Learn how to interpret those images

Training is critical, and a good distribution/manufacturing team can make all the difference in helping a practice get up and running quickly. Dr. Mathis says the time it takes to train a new technician varies. Some people are good at picking things up fast, within a week or two, she says, but that’s generally the exception and not the rule. People do pretty well within 1-3 months, but that’s only if they are using the equipment on a regular basis.

When Dr. Mathis attends lectures with other veterinarians on dentistry, she finds that many colleagues are frustrated that it’s taking them much longer than anticipated to take the X-rays.

“You should be able to take a full-mouth series in 6-10 minutes,” she says. “Even if it’s 15 minutes, that’s fine. But many people are taking longer – like a half an hour to get these images. That’s where you need to practice.” Specimens and model skulls are options to bring team members up to speed.

The client visit
For clients that seem reluctant that their pet even needs dental procedures, Mathis says her practice uses a simple test, OraStrip, as the first step in determining if there are hidden dental problems. OraStrip tests for the presence of bacterial thiols that are present with advancing periodontal disease. It directly correlates with the loss of bone around teeth. Using its scale of 0-5, a veterinarian can determine the likelihood of problems beneath the gum line. “With 1s, there might be something going on, but if it is between 2-5, you have at least an 82 percent chance, if not a 100 percent chance, of having periodontal disease, and/or bone loss,” says Mathis. “OraStrip is an inexpensive test that you wipe along the gum lines. In 10 seconds, I can see what the chances are that there is a problem in the mouth. It is also a visual take home test that reinforces the need to take action.”

With or without OraStrip, all patients undergoing an anesthetic dental procedure need full mouth radiographs in their medical files. Common radiographic findings could include retained tooth roots, tooth resorption, near jaw fractures, unerupted teeth, cysts, dead teeth, causes of nasal issues, bone involvement with oral masses, and more.

Home care is also an important topic. Successful buy-in and compliance for the clients at home will only happen if the veterinarians and their staff are fully committed in the practice, says Jessica Bayer, Director, US Pets Therapeutics, Merial. Bayer says veterinarians can integrate the need for maintaining good oral health as a practice philosophy through several benchmarks:

  • Establishing Standards of Excellence in oral care
  • Making an oral exam a part of every examination
  • Maintaining a consistent message within the team
  • Consistency of oral care services among ALL providers in the hospital
  • Consistency of knowledge among ALL levels of the veterinary care team

Vet-Advantage December Companion 2017 - Open Wide, Conversation StartersThe oral exams will be where the veterinary practice discovers the best method of treatment, or preventive measures to help pets avoid periodontal disease. Home care should be part of that discussion to ensure a higher compliance rate. For instance, by advising clinics to include a box of OraVet Dental Hygiene Chews as part of the home care protocol after every dental procedure, many clinics have experienced complete client and patient acceptance, leading to long term use, Bayer says. In one particular instance, by motivating the staff through education, merchandising, client giveaways, and staff giveaways, a representative helped a clinic progress from only selling a few boxes of OraVet Dental Hygiene Chews a week, to over 80 boxes a week.

“All members of the veterinary team (from receptionists, technicians, practice managers, associate veterinarians, and practice owners) must be excited, motivated, and have developed clearly established uniform standards of veterinary care,” Bayer says. “One of the challenges for many practices is to achieve complete alignment between all team members.”

Make the connection
Indeed, due to its connection to overall health, periodontal disease isn’t a topic veterinary practices should shy away from. Whether it’s treating acute conditions caused by periodontal disease, encouraging clients to invest in routine cleanings and digital X-rays, or gaining compliance with home care products, there’s a lot of quality veterinary medicine to practice – as well as revenue to be had – for clinics willing to invest in providing dental care services.

“I want veterinarians to learn what to do when it comes to dentistry, because our job is to be the patient advocate and tell owners what’s going on with their pet’s health,” says Dr. Mathis.  

Topics: Cover Story, Dental, Dentistry


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