In my last post, I blogged about my recent visit to the Colorado Veterinary Medical Association for their Big Ideas Forum, the focus of which was "Veterinary Dentistry: Is there a Standard of Care?" I covered the first part of that discussion in my last blog on equine dentistry and Non-Veterinarian Dental Care Providers. The other discussion that transpired was a boisterous state of the industry for pet dentistry. One of the topics we covered was sedated ("anesthesia-free") dental procedures.

Although I appreciate that many practices do not have the capacity or staff training necessary to do thorough charting, cleaning, and dental X-rays, I feel it is more than a little disingenuous to call their procedures dentals when in fact they aren't at all. So no matter how I try to be sympathetic and understanding of the people practicing dentistry differently than what the guidelines dictate, I cannot find it within myself to bend to doing it their way. We have too much scientific evidence proving this is not good medicine. And in my heart, I know there is no way I would take my own beloved four-leggeds and put them under heavy sedation without an ET tube and allow someone to clean their teeth without X-rays or charting. They are just too important to me.

The big question that I asked, and continue to ask, is "How do we enable clients to become effective consumers and to understand the medical standards that may or may not go into a procedure?" There will always be people who do not want or cannot afford the type of care found at a well-managed hospital. But I believe there are a much larger number who would be appalled if they discovered that they were not getting the type of care that they thought they were purchasing. So how do we bridge the client-veterinarian communication gap?

It is critical that we serve the needs of our clients within our mission, vision, and values. It is also important that we adhere to the scope of practice standards within our respective states. As AAHA hospitals, we also need to adhere to AAHA standards. Most of the general public does not understand that there is no common level of standards such as exists in human medicine. It is important that each of us describes our standards to clients and potential clients to help them make informed choices when it comes to their pets.

We need to help clients understand that veterinarians are not all the same. A client cannot choose based solely on location or price if they are looking for someone who adheres to high standards and seeks to attain the recommendations made in the guidelines. Clients must become more sophisticated with their choice of veterinarian. If they want high quality, it is important they find an excellent primary care veterinarian that will help guide their pets' health care plan.

If we teach clients to be more effective in choosing their veterinary care providers, we can help ensure that clients are spending their health care dollars on the kind of care they want for their pets.

Comments (6) -

Carol S
Carol SUnited States
6/17/2013 7:33:30 AM #

Dr. Knutson,
As a parent of a 5y/o Yorkie, I generally agree with your position. However, I challenge you & your colleagues 2 come up with an alternative 4 special situations.
In August 2012, our then 4 1/2 y/o was due 4 his annual teeth cleaning, but instead had 2nd episode of Pancreatitis. We postponed the teeth - $ & high liver values.
October 2012 he is dx w Diabetes - liver values r down but now unknown BS stability. Hold the dental on advice from vet. Put on W/D diet
December 2012 - 3rd round of Pancreatitis. Liver values back up. Colleague vet suggests changing diet to I/D. We hold off on that & then try in in February 2013. Sends his sugars sky high & out of control - back 2 W/D.
Early April 2013 - Cataracts. Vet opthomologist. Multiple eye drops 2 prep 4 surgery.
Late April 2013 - HGE - in ICU 24 hrs and step-down 3 days.
May 2013 - bilateral cataracts removed & lens implants
June 2013 - teeth & gums r in poor condition. We r financially broke & can't even afford 2 have his sister's teeth cleaned (Maltese). Even if we could afford it, our vet refuses 2 give anesthesia siting glucose instability n slight  elevated liver values. Did I mention he has terrible seasonal allergies?
What to do? The brother of the opthomologist is a vet dental specialist n he might consider cleaning his teeth. But like I said, we're flat broke.
There's your challenge. Hope u can come up with something!

Michael Tenzer
Michael TenzerUnited States
6/28/2013 4:12:47 AM #

To Carol S.
That's awful that  this poor yorkie has had way more than his fair share of problems and you've obviously dedicated yourself to taking care of him. I'm a vet and I'm not sure there's a good solution until you can save up enough and catch a break from any new crises to go forward with the oral procedure. The alternative is that he may live in pain until that happens.
What I'll take away from your challenge is that I'll increase my efforts to encourage my clients to get a good insurance plan for their pets so that all these things won't break them financially and they don't have to delay important treatments.
As a side note I think breeders aren't doing a very good job selecting heartier breeding dogs. This seems like a lot of problems for one little dog and I wonder how much is bad luck or if the breeder has any chronic problems with overall health in their litters. The breeders take their money and never seem to be around when stuff hits the fan!
Good luck to you and your two dogs.

DrDennisUnited States
6/28/2013 4:55:33 AM #

Carol: sorry to hear about your dog's ongoing health issues. Diabetes and mildly elevated liver enzymes are not contraindications to anesthesia and dental work in my opinion ...but I don't know your dog's specific situation. Not really sure what you're asking Dr Knutson to come up with -we all have clients with financial limitations and barriers. That does not mean we practice substandard care for their pets. But there are ways to get things done for less money that will not compromise patient care in many cases. You just need to find a good veterinarian who can be flexible while maintaining high standards. And in the case of multiple medical issues, you need to set priorities

Arnold L. Goldman DVM
Arnold L. Goldman DVMUnited States
6/28/2013 5:23:02 AM #

Dear Carol S.,

As the owner of your 5 year old Yorkie, you, with the help of your veterinarian, have to prioritize the medical problems your pet has, and if that means some things are left untreated, so be it. Your implied exception to the rule regarding ethical pet dentistry does not alter the truth of Dr. Knutson's statements. If an intervention cannot be done ethically and properly,  its better not to be done at all.

Specifically,  an "annual teeth cleaning" can be delayed or cancelled as needed.
Whereas pancreatitis, diabetes and HGE are far, far higher priorities and must be treated right then and there.
Holding off on the "dental on advice from vet" is excellent and appropriate advice. Your veterinarian deserves kudos for good judgement.

As far as cataract removals & lens implants, while these may be considered elective as well, it is a judgment call whether dentistry is of a higher priority at any given time. It depends which problem is causing the greatest decrement to quality of life and health.

So now, with "teeth & gums r in poor condition" and you "r financially broke & can't even afford 2 have his sister's teeth cleaned" you are again faced with a new set of priorities. In this case you have to prioritize your own needs for a time to catch up. Understandable and reasonable. The dentistry will just have to wait some more.

Regarding, "our vet refuses 2 give anesthesia siting glucose instability n slight  elevated liver values" you may have discovered a philosophical difference with your veterinarian relative to prioritizing your pet's problems, and it may be prudent to seek a second opinion.

As a colleague of Dr. Knutson, and as a veterinarian similarly sympathetic to my clients' individual financial  situations, it can be a challenge to help people properly prioritize what their pets need in light of what's possible and necessary. Nevertheless, anything you may choose to have done, should be done ethically. You said it best when you said, "There's your challenge. Hope u can come up with something!"

Arnold L. Goldman DVM, MPH
Canton, CT

clayton mackay
clayton mackayCanada
6/28/2013 6:36:31 AM #

Carol, a predicament being faced by many pet owners today. As a 2nd generation veterinarian, I have lived in this profession my entire working life. It is interesting that as companion animal practice aproaches the ability to provide care that matches in many ways those of human medicine, the cost of  delivering that care now overcomes many household budgets. AAHA has been a leader in improving first the facility in which the care is provided and now in the standards by which the practicing profession may be judged for its competency in the future. All of this leads to much better care for our patients, however, there appears to be a lack of focus on the effectiveness or efficiency of delivering such care. As pointed out in major surveys, although this care is available, the use by the public is declining particularly in the health and preventive care situation. As this escalates, more patients will require more extensive medical and surgical care because of the lack of preventive care, early detection of disease and interventional treatment.
I believe as a long time advocate for my profession, that it must begin to consider major changes in the delivery of our services to utilize new ways of providing care in a much more efficient manner. Every veterinary practice cannot be equipped to be a major hospital facility by itself. Building 1 major hospital in a geographic locale to maximize the investment in facility and specialized technology on a 24 hour basis could decrease the overhead in providing this care. Surronding that could be veterinary offices that could provide the general health and preventive care at an overhead cost about 1/3 to 1/2 of present day fees.
While none of this solves your current problem, we as veterinarians must solve this in the long run to provide our ever improving medical skills in a price range for the average consumer, not only for the super rich. In my long time clinical career, there was no direct relation to the wealth of the owner and importance of that pet in their lives.!

LaNellUnited States
10/26/2013 6:56:04 AM #

To Sue S....have you tried to barter out by offering car or home  or office cleaning? Or other skilled things you can do? This is also better tax-wise for the vet.

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