Aug
5
2013

AAHA-accredited members may have noticed an important change to the dentistry standards that were sent via email Aug. 1. AAHA's new mandatory dental standard will impact practices scheduled for their evaluation on or after Nov. 1, 2013. Below, we share some facts about the new standard.

What is the new mandatory dental standard?
MA 11.6: All dental procedures are performed under general anesthesia with patients intubated.

What has changed?
This standard changed from a points-based standard (DE01, worth 100 points) to a mandatory standard requiring that all dental procedures be performed under general anesthesia with patients intubated.

Why did the AAHA Board of Directors decide to make this change?
The introduction of the 2013 AAHA Dental Care Guidelines for Dogs and Cats, approved and endorsed by the American Veterinary Dental College, prompted AAHA to update the Dentistry Section of the standards. The Guidelines state that cleaning a companion animal's teeth without general anesthesia is considered unacceptable and below the standard of care. General anesthesia with intubation is necessary to properly assess and treat the companion animal dental patient. The use of general anesthesia allows for the necessary immobilization without discomfort, periodontal probing, intraoral radiology, and the removal of plaque and tartar above and below the gum line including polishing to ensure patient health and safety. Because AAHA-accredited hospitals are expected to practice the highest level of veterinary medicine, AAHA's leadership felt it necessary to update the standards to reflect best practices outlined in the Guidelines.

How will this change impact practices applying for accreditation?
Any members scheduled for their evaluation on or after Nov. 1, 2013 will be required to comply with MA 11.6 in order to pass their evaluation and achieve accredited status.

How will this impact AAHA-accredited practices?
While we hope accredited practices will implement the standard immediately, we will not assess their compliance until their next onsite evaluation.

Why is general anesthesia necessary for companion animal dental procedures?
At least 60 percent of normal tooth structure for both cats and dogs is under the gum line. Partially removing plaque and tartar from the exposed crown is more cosmetic than therapeutic. Removing the plaque and tartar from both above and below the gingiva on the lingual and buccal surfaces requires general anesthesia and results in a cosmetic as well as therapeutic outcome. General anesthesia also facilitates proper pain-free probing of each tooth's support and the required immobilization necessary to take intraoral dental films. Finally, intubation during general anesthesia protects the trachea and prevents aspiration of water and oral debris.

Questions? Contact your practice consultant for more information.

 

Comments (30) -

Kristy Lund
Kristy LundUnited States
8/7/2013 7:55:31 PM #

I would like to know what scientific proof they
Based their decision on. Have they done a com-
parison study comparing anesthetic vs
non-anesthetic cleanings done by trained
hygienists.. not the cleanings that are
being done in the back rooms of grooming
pallors without veterinary supervision? If
I stop performing non- anesthetic denials
I fear owners who have been happy with
the results will seek out groomers etc who
Perform the procedure and now it will
be harmfull to the pet and cause problems
because it isn't supervised by me. And what
do I tell these clients... Sorry we decided
It is now harmfull?? I would be lying
because I believe it's a valuable procedure
I have done on my own pets. And what about
the clients who won't anesthetize their pets.
just let the teeth rot..what kind of standard
of care is that? I finally have many clients
on a preventative teeth cleaning schedule
that is improving their pets life's and some
one in a board room who may have never
even seen the procedure performed makes
decision that affects not only the well
being of my patients but also eliminates
a large source of revenue for the hospital .
I am up for renewal and have been a
member for over 20 years but this is
making me take a hard look if Aaha
Accreditation is worth it. I think this time
you have gone too far.. you are telling
me how to practice medicine without backing
it up with scientific proof. Have you surveyed
all your Aaha practices to see how many
Provide this service and believe in it?

AAHA
AAHAUnited States
8/23/2013 2:23:48 PM #

Kristy,

Thank you for voicing your opinion on this important issue. While we recognize that there is disagreement on this issue, we celebrate that it sounds like there is common ground in that we are both concerned with the best interest of the pet.

As for what you tell your clients, we suggest explaining to them that just like people medicine, veterinary medicine is in a constant state of change. Veterinary medicine has evolved over time - as an example, hanging dogs from their hind legs used to be the standard for abdominal surgery in the early 1900s.

While not comparing this to the practice of dentistry, dentistry standards also evolve as our knowledge base is expanded. Medicine must be in a constant state of evolution so that we may continue to provide better care for our patients.

The AAHA standards are not determined by a popular vote by our members – our standards are revised and updated by experts who determine that the changes are the medically right things to do, even if it may seem controversial at first glance. The 2013 AAHA Dental Guidelines for Dogs and Cats state that general anesthesia with intubation is necessary to properly assess and treat the companion animal dental patient. Because AAHA practices are expected to practice the highest level of veterinary excellence, AAHA’s leadership determined it necessary to update this standard to reflect the best practices outlined in the Guidelines.

Additionally, we firmly believe that the loss in revenue, while only a secondary issue, can be made up in other health care areas including preventive care.

While we recognize that not everyone will agree with the new mandatory standard, we firmly believe this is in the best interests of pets. The AAHA Board of Directors welcomes any further feedback – members are welcome to share their perspective by emailing aahapresident@aahanet.org.

-The AAHA Team

Kimberly Cook
Kimberly CookUnited States
8/29/2013 5:36:10 AM #

I am not happy with this decision. Again the government is telling us how to do something. There are people who believe in natural ways of healing and caring for people and animals. This takes away from our CHOICE to do it this way.

Kimberly Cook
Kimberly Cook
8/29/2013 5:55:48 AM #

I can't believe you are comparing this to hanging dogs from their legs for abdominal surgery in the 1900's!!!! Not a very good argument. This is not evolving. Medically the right thing to do? Right, it is such a good thing to put animals under anesthesia, because it is so safe and it cannot harm an animal in any way and it is so good to drug up an animal just to clean their teeth. Medically in this country the answer is always, just give them a pill or some kind of drug. It is sad. I am not saying that there is never a need to anesthesia. Somehow this will increase revenue not hurt it or this decision would not have been made.

amber
amberUnited States
8/30/2013 10:32:36 AM #

I am happy with this decision. I think dental care is important in pets and I think putting them under is the right way to do it. Just like stated above, it is A. easier for the patient and tech/dr while cleaning teeth. B. it is more effective to clean the teeth while they're under. How do you know you're truly getting under the gum line when a dog or cat is yanking away, moving their head etc during a NAD? The comparison to hanging dogs up for abd. procedures is a little out there though. However, AAHA is correct in stating that medicine is always evolving. Anyways, I think this is a good change.

Arnold L. Goldman DVM
Arnold L. Goldman DVMUnited States
8/30/2013 11:50:57 AM #

Dentistry in pets is performed using general anesthesia to protect the airway from aspiration of debris, saliva or prophy paste, to allow proper and thorough dental radiography, to allow subgingival curettage, to polish out microscratches from hand scaling and to provide adequate and safe restraint for all of the above.

All sorts of excuses are made by lay persons, skirting practice acts while engaged in non-anesthetic "dentistry" about why their methods are safe and effective. Certainly our profession opposes such people because we oppose "the ways of the charlatan." As licensed professionals, we are expected to perform at a higher standard than such people, indeed at the highest standard. Trying to defend the indefensible denigrates our profession.

Regarding "If I stop performing non- anesthetic denials (sic) I fear owners who have been happy with
the results will seek out groomers etc who Perform the procedure and now it will be harmfull to the pet and cause problems because it isn't supervised by me."  The point is, it already is just as harmful and counterproductive when YOU do it, as when a charlatan does it. There is no need for you to lower yourself to
their level. The pets are suffering because of their owners, not because you didnt offer the highest level of service. Untreated mild and moderate gingival disease may be better than an incomplete or improperly conducted "prophylaxis."

Regarding: "And what do I tell these clients... Sorry we decided It is now harmful??"
Yes, that's exactly what you tell them, and carry your head high thereafter.

Karina
KarinaUnited States
8/30/2013 11:52:06 AM #

I am so pleased that AAHA is implementing this new standard. As an AAHA-accredited practice, we make every effort to educate our clients about the reasons behind quality recommendations. I personally probably would not use the example of hanging dogs from their hind legs for abdominal surgery to convince our clients of the value of dentals performed under anesthesia. I like to explain to skeptical clients that, unlike with people, animals cannot understand the benefit of holding their head perfectly still for a period of time to withstand scraping, poking, prodding, and polishing. And, we don't want to do anything that would cause any discomfort to their baby!  Also, we do understand that, like many of us, our clients find veterinary care cost-prohibitve. As a practice, we would rather work with our clients to help them afford quality care than to decrease the quality of care that we provide. One approach we have had success with is to encourage interested clients to make monthly pre-payments to "save up" for the dental. Once they have 50% to 100% of the estimate waiting as a credit on their account, we perform the dental (obviously we handle things differently with more urgent cases).

Arnold L. Goldman DVM
Arnold L. Goldman DVMUnited States
8/30/2013 11:54:53 AM #

By the way, bravo to AAHA, for asking something more of its accredited members. There will be those who disagree and may refuse to renew because of that disagreement. If AAHA accreditation is to mean anything at all, it has to mean the highest standard, rather than whatever is the lowest common denominator of its members.

AAHA
AAHAUnited States
8/30/2013 12:31:00 PM #

For client information about the new standard, and for information on anesthetic dentals, please visit the AAHA
pet owner website: www.healthypet.com/.../...r-dental-procedures.aspx

Karina
KarinaUnited States
8/30/2013 12:46:38 PM #

[By the way, bravo to AAHA, for asking something more of its accredited members. There will be those who disagree and may refuse to renew because of that disagreement. If AAHA accreditation is to mean anything at all, it has to mean the highest standard, rather than whatever is the lowest common denominator of its members.]Bravo, Dr. Goldman!  I must say I appreciate your clarity of thinking.

Ken
KenUnited States
8/30/2013 1:12:20 PM #

That is the dumbest comparison I have ever heard. Hanging a dog upside down?  Who is doing the writing for AAHA? You people at AAHA need to go back and resharpen your pencils and please come up with something we can understand. You have done no research regarding this procedure except for listening to Dr. Bellows talk about some groomers that has no clue with what they are doing. There are over 800 practices in the nation providing this service, are they all wrong? I don't think so.  If you have not seen this procedure in a hospital environment you should not be posting an opinion.  That means you Dr. Goldman.  Why are you so afraid of this procedure? Afraid to the point that you burry your head in the sand and just say no instead of actually viewing it with your own eyes. It is very hypocritical of you. You are all vomiting the same excuses and are too afraid to be open minded about new things that benefit all parties involved.  Obviously your handling skills with animals must be pretty bad, if you need your patients to be anesthetized for you to do anything.  By the way, what should we do with pets that are anesthesia risk? Let their teeth rot out of their head with no care?  I can guarantee our dental cleanings are up to par with us providing services to hundreds of vet hospitals and thousands of customers. I invite you anytime to critique our work and you might even learn a thing or two but I am sure this is falling on deaf ears as it has always in the past. Please stop comparing the professional companies with the lay people in groomers and pet stores.

AAHA
AAHAUnited States
8/30/2013 2:20:09 PM #

CLARIFICATION: The intent of the comment about hanging dogs from their hind legs was simply to demonstrate that veterinary medicine has evolved over time, and continues to evolve. We are not comparing this practice to non-anesthetic dentals. The comment should simply be taken as an example of how veterinary medicine has evolved over the years.

-The AAHA Team

Michael Borin
Michael BorinUnited States
8/30/2013 2:55:27 PM #

I’m sorry but AAHA got it wrong. They proclaim that their decision was based on evidence based medicine. They assumed that the Dental College has it right. The Dental College’s position was based on conjecture and illogical anecdotes.   Comparing non anesthetic cleanings to anesthetic dentals is not useful. Unfortunately pet stores and groomers advertise this as replacement and that’s where a lot of the confusion comes from. Doctors that use the service use it as part of a spectrum of dental care that is made available to their patients and clients. Our general population of dogs and cats continue to have rotten teeth. Some “A” clients will do what is necessary to maintain clean teeth, but the majority of clients either never have dental work or have work done once and then again maybe 3-4 years later when the teeth are showing signs of periodontal disease again. I’ve observed the use of non anesthetic cleanings in hospitals now for over 7 years. I have seen it increase compliance and impact the prevention of periodontal disease. It gets owners involved in dental care and often they become willing to place their animals under anesthesia when advised by a doctor. Doctors continue to recommend dental x-rays under anesthesia and clients seem to be much more willing to do what the doctor recommends when they believe the doctor has the patient’s best interest in mind.

Let’s look at the dental college’s objections:

“1. Dental tartar is firmly adhered to the surface of the teeth. Scaling to remove tartar is accomplished using ultrasonic and sonic power scalers, plus hand instruments that must have a sharp working edge to be used effectively. 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. “

Have they actually observed the procedure performed by a well trained technician? I doubt if the many doctors who use the service would do so if the above was true. In my 7 years of observation I have not found this to be true.”

“2. Professional dental scaling includes scaling the surfaces of the teeth both above and below the gingival margin (gum line), followed by dental polishing. The most critical part of a dental scaling procedure is scaling the tooth surfaces that are within the gingival pocket (the sungingival space between the gum and the root), where periodontal disease is active. Because the patient cooperates, dental scaling of human teeth performed by a professional trained in the procedures can be completed successfully without anesthesia. However, access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient. Removal of dental tartar on the visible surfaces of the teeth has little effect on a pet’s health, and provides a false sense of accomplishment. The effect is purely cosmetic. “



Again, I refer to my comments on the first point. Are these statements based on conjecture? Or anecdotal evidence from those done in pet stores? I believe the professional doctors using this service are aware that an effective dental has to get below the gum line, and I’m confident that they would not allow a service that was not effective, they have made their conclusions by actual observation.

“3.Inhalation anesthesia using a cuffed endotracheal tube provides three important advantages—the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examinations and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.”

Again, conjecture?  I’ve seen many more cases of traumatized tracheas from intubation than aspiration from non anesthetic dentals. Again, perhaps the Dental College has seen these from poorly trained technicians who perform them in pet stores? I have not seen an aspiration problem in 7 years. The technicians have developed a method that captures debris.

“4. A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient. The surfaces of the teeth facing the tongue cannot be examined, and areas of disease and discomfort are likely to be missed. “

I have seen over and over again where the well trained non anesthetic technician has found mobile teeth or deep pockets that were missed by the doctor. Then, when specific problems are pointed out by the doctor to the client, the clients are almost always willing to have an anesthetic procedure done to take care of the issue. Over and over again, periodontal disease is detected and then dealt with under anesthesia. Often these issues would have gone on unnoticed had they not agreed to a cleaning.

So when we say “highest standard” do we mean that we can take great care of the 5-10% clients who have enough money and are willing to place their animals under anesthesia often to perform what is necessary or are our goals to improve the general population’s dental health? Both are important, and I would not criticize any doctor that is not comfortable using non anesthetic dental cleanings as long its based on an open mind. When utilized properly, as I believe most AAHA doctors are capable of doing, this procedure adds to most dental programs by increasing compliance and adding a tool for prevention of periodontal disease. If AAHA wanted to set guidelines I believe these would be welcomed by those who do this responsively. AAHA, as a protective agent for the general public, is not contributing to the well being of the general companion animal population by abandoning this procedure.

I would hope that some day AAHA and the Dental Board will take a deeper look at this and assist in developing this as an added tool for prevention of periodontal disease.

Arnold L. Goldman DVM
Arnold L. Goldman DVMUnited States
8/30/2013 3:45:05 PM #

Dear Ken,

I do not have to defend my profession's ethical standards to you or anyone else. They are what they are. Anything can be justified in an ends justifying the means format. I choose to defer to the Dental College, to the AVMA Principles of Veterinary Medical Ethics, to the AAHA standards and others because I recognize that I do not know everything and that I do not know better than board certified dental specialists, who have a deeper and broader experience in their areas than I can ever hope to have.

I am not "afraid" of this procedure or any other method, but the evidence points towards anesthetized dentistry as the standard, one which you clearly reject. I do not claim to know better than the boarded specialists, as that would be the epitome of arrogance. My own eyes are no substitute for randomized controlled trials that have lead the specialists to define the standards for dentistry in pets. Choose to ignore them at your own ethical peril. I choose not to.

Regarding: "what should we do with pets that are anesthesia risk?" Either anesthetize them in a safe manner or refer the case to someone who can.

Respectfully,

ALG

Ken
KenUnited States
8/30/2013 9:42:03 PM #

Dr Goldman,

You are right. This should not be an attack on you or anyone else, I guess my deep frustration shows. You are certainly free to practice medicine as you want to as long as it contributes and does not cause harm. I did not mean to give the impression that anesthesia dentistry is not important. It is the standard and should remain so. Anesthesia free dentistry is an added tool that a veterinarian can use to increase compliance and keep the teeth clean between regular anesthetic dentals to assist in the prevention of periodontal disease.  I also have a lot of respect for the dental college, they have moved the field tremendously in a positive way and do amazing things for the treatment of periodontal disease.  However it is my belief that we should always question and I feel that statements made by the dental board , AAHA and others in regards to anesthesia free dental cleanings are not well substantiated.

Ken

Aldo M
Aldo MUnited States
9/1/2013 2:52:16 PM #

I do believe that AAHA has the right to set standards and regulations for hospitals. Most of the AAHA requirements and regulations are definitely in the best interest of the patient and the hospital. Unfortunately, I personally don't agree with their decision regarding non-anesthetic dental cleanings (NAD’s). We are an AAHA approved hospital and when our owner heard of the new standards set by AHAA he was very upset. He said he would not be renewing our AAHA accreditation if they would not approve of non-anesthetic dentals at our hospital. I am a registered technician and have been doing anesthetic dentals for over 8 years. We have had the non-anesthetic dental cleaning performed at our hospital for as long as I’ve worked here. We have never had any issues. I have personally sat next to the technician while he was performing a non-anesthetic dental. They clean all surfaces of the tooth including 2-3mm under the gum line, inside and out. They also machine polish every one of the teeth and complete a very thorough charting of any pathology found. I always read on blogs and hear from other veterinarians that relief at our hospital that they believe it makes people not want to do anesthetic dentals. That is definitely not the case at our hospital, most of our anesthetic dentals are pets that were scheduled for NAD’s but the technician found pathology while doing their oral exam. We find that people are more willing to follow up with anesthetic dentals when pathology is found during an NAD. I don't believe AAHA has done enough research about this procedure and definitely did not ask our opinion on the matter. I found it comical when we received an email asking our opinion on changing the design of the AAHA logo. Yet, they did not consider asking our hospital who has provided NAD’s for over 12 years a single question on the matter. I find it to be very unprofessional that they are classifying all non-anesthetic dental companies in the same group. We have had Animal Dental Care as our provider of NAD’s. I can personally attest to the fact that they practice their procedures to the gold standard. We will continue using their services because it is a vital tool in dentistry at our practice.

Debbie Zabrowski
Debbie ZabrowskiUnited States
9/3/2013 5:45:13 PM #

I find it hard to believe that any hospital,  AAHA or not, would consider not having an animal under anesthesia for dental cleaning.  We  had a client who took his dog for non-anesthetic cleanings for years. He came in one day with an abscessed K-9 tooth, once under anesthesia and a proper exam could be done there were many teeth that needed to be extracted. No one is able to properly clean teeth without anesthesia, especially on small breed dogs who are famous for periodontal disease.

Dr. Mayra
Dr. Mayra United States
9/4/2013 5:08:50 PM #

My name is Dr Mayra Urbieta, and I am a (human) periodontist. I have been working with Pet Dental Services for four years now. I completed my undergraduate work at Georgetown University, received my dental degree at Boston University, and completed my 3-year residency in Periodontics at Nova Southeastern University in Ft Lauderdale. I currently oversee the training of our hygienists and their study materials, which have been compiled using a combination of both human and veterinary dental literature to ensure the most accurate and complete program possible. An 11-step procedure was created to ensure continuity among the hygienists, allowing us, as a company, to be consistent with the quality of our service. I was brought on board to ensure that PDS would be able to offer the same value of service to pets that is expected from a human hygienist working under a periodontist. Working for PDS has allowed me to be involved with veterinary dentistry to a certain extent, giving me the opportunity to implement my 7 years of dental training into a service that is so valuable—a service that allows pets to be on a recall system that resembles that of human dentistry, thus providing them with true preventive dental care and maintenance.

I applaud those who are cautioning against the traditional NAD. I too am familiar with the perils of stereotypical anesthesia-free dentistry in pets, and thus the stigma that surrounds such a practice and has lead to the AVDC's position on the matter. Unfortunately, because there is currently no official training program or regulatory group for dentistry without anesthesia, there are many companies performing this procedure who truly have a limited knowledge, if any, of dentistry.

However, I respectfully disagree with several of the arguments made in these comments, namely with the generalizations. Not every NAD or practitioner of such is created equal, and a procedure should not be deemed impossible or inadequate merely because it is difficult. Although anesthetic dentistry is very safe, it would be considered equally unsafe if carried out by an untrained person outside of a veterinary hospital.
NAD should only be performed under the direct supervision of a veterinarian because it is a medical procedure. When performed correctly by highly-trained professionals and prescribed appropriately by veterinarians the benefits of non-anesthetic dentistry can be extremely valuable. Yet it is important to recognize the scope of the procedure. Like any procedure performed by an auxiliary to a veterinarian, it is to be used at the discretion of the veterinarian, for the veterinarian is ultimately responsible for the overall health of each patient. It is up to the doctor to decide when and for what patients the service is appropriate. In addition, auxiliaries should never be expected to diagnose, but to recognize pathology, so that they may bring it to the attention of the veterinarian and know their limitations when performing a prophylaxis. It is this ability to recognize pathology that increases the numbers of anesthetic dentals performed in the hospitals where our services are provided and the countless referrals that are sent out to the veterinary dentists in those areas. Similarly, periodontists and (human) dentists depend on hygienists to recognize and make them aware of oral pathology that may arise between yearly examinations.

Non-anesthetic dentistry is not meant to be an alternative to anesthetic dentistry, but to support it. It should not be promoted for its “affordability” or because it is considered “safer” than anesthetic dentistry, but as an adjunctive service.
During the training of our hygienists, I often use the metaphor of human pediatric dentistry. Although the AVDC suggests that human dentistry can be performed without anesthesia because the patient can cooperate, they don't take into account pediatric dentistry, which is structured completely around behavioral management. Only children that need full mouth restorations or have extreme behavioral problems are treated under general anesthesia. The only difference between pediatric dentistry and non-anesthetic dentistry in pets is the ability to take a dental xray, which then brings into question the frequency with which dental xrays should be taken. Currently there are no set guidelines for such a timeline and a large percentage of veterinarians do not have access to dental xrays, thus it is up to the doctor to decide at what point xrays are necessary and to perform an anesthetic dental or refer to a veterinary dentist at that time. Again, the veterinarian is responsible for the overall treatment plan of each patient.
The bottom line? Not every NAD or practitioner of such is created equal. Pet Dental Services provides a high-quality POPD, offering veterinarians an additional service to prescribe at their discretion on the appropriate candidates. It is medically beneficial to the pets, allowing them to be on a maintenance program in the intervals between anesthetic dentals.

Michael Borin DVM
Michael Borin DVMUnited States
9/6/2013 9:41:13 AM #

Debbie Zabrowkski, Anecdotal evidence is often good but it must be investigated thoroughly.
"He came in one day with an abscessed K-9 tooth, once under anesthesia and a proper exam could be done there were many teeth that needed to be extracted. "
Where was this done? was it done under the supervision of a doctor? what were the recommendations? was the client well educated to what was needed? was this done by a well trained technician? etc.?  Additionally a dental cleaning absolutely can be done without anesthesia, it is not meant to treat progressed periodonatl disease.

Barak Benaryeh
Barak BenaryehUnited States
9/6/2013 1:15:25 PM #

I have read the comments pro and con for non-anesthetic dental.  As we are all aware, a single case gone wrong has no bearing on a greater medical discussion.  The question at hand is whether a an all encompassing policy is appropriate.  The same question has been asked in regards to pit bulls.  Do you ban the entire breed for the actions of a few?  I am not in favor of banning pit bulls and I am not in favor of banning non-anesthetic dentals.  Like many other facets of veterinary practice, NAD's can be used appropriately and inappropriately.  We are an AAHA accredited facility and we allow the occasional non-anesthetic dental.  I do not believe that non-anesthetic dentals should be the norm nor even the majority of dental cleanings but they do have their place.  There are some cases that benefit.  Like anything else it is up to the doctor in charge to use the service or technique appropriately.  There are so many treatments that have been used inappropriately over the years that have done so much harm yet we have banned none of them - depo-medrol, vetalog, flocillin, FIP vaccination and quite a number of others jump to my mind.  We have banned none of these.  The presumption is that there may be a small number of cases that benefit.  If treatments are used inappropriately the liability as well as the negative impact to your patients is on your head.  These have not been disallowed by AAHA because there are small numbers of cases that may benefit - the same is true with non-anesthetic dentals.   I believe decisions should be left to qualified practitioners.  That is what they were trained for.  The more restrictions we put on our own profession and the less faith we put in the hands of those who practice, it will only be to our own detriment.
I am in favor of quality practice and I am in favor of choice.
Barak Benaryeh DVM, DABVP

Kevin S
Kevin SUnited States
9/6/2013 1:23:20 PM #

Please explain why you have decided to mandate pass fail on this aspect of dentistry but not on dental x-rays ? You mean to tell me you will make such an aggressive stance on this, however you will continue to accredit clinics that perform extractions without dental RADS ?  When do you plan to change this to a pass fail?

Timothy R Kraabel
Timothy R KraabelUnited States
9/7/2013 10:38:16 AM #

AAHA and the dental college have missed this one.
  
I own a busy 6 doctor practice that has provided NAD through animal dental care for many years.  I was against NAD for the first several decades I was in practice and, like many of you, routinely regurgitated the perils of NAD as speculated by the dental college.  I, again like many of you, had never seen the procedure performed at all, much less by someone qualified.  

A very specific animal and client pushed the issue with us.  I was her vet and she wanted me involved.  she found animal dental care and through a battle of will and time got me to allow and watch a NAD at my hospital.  It is impressive to watch.  Real clinical goals are accomplished.  The technicians are thorough, get under the gumline, and there is no risk of aspirating. If an animal is uncooperative, they just don't do it.  They stop if disease is present that they can't handle and they drive anesthesia dentals by their findings more than I could have ever imagined.   We do more anesthesia dentals because we provide non-anesthesia dentals.

Realize when we discuss this that NAD and an anesthetic dentals are not the same thing and we do not have the same expectations from them nor do we discuss them as equals.  Despite our defense of NAD, we still go to anesthesia 80-90% of the time as a practice.

NAD has a niche in care that I've watched emerge as part of our scope of dental care.  Some clients will go to it much earlier in life if given the choice and they often pursue it much earlier between anesthetic cleanings.  The really remarkable niche is for the client that won't allow anesthesia.  We all have them or we aren't paying attention. And while I could sell water to a drowning man and am a huge believer in, and proponent of, safe anesthesia, not all of my recommendations are followed.  These anesthesia fearing people are often some of our best clients and they WANT to provide dental care but can't get past the fear.  By supporting them and allowing care within what they will emotionally allow, you get to help.   These animals typically go completely untreated or go to substandard locales like the pet shop.  The other kicker is a significant number of these clients will then go for further anesthetic dental care when the dental technician finds pathology.  This scenario plays out all the time.  The original cat I referenced has had three anesthetic cleanings and several teeth pulled since the original NAD.  None of that care would have happened if I hadn't allowed the NAD.

AAHA is imposing the will of a specialty college that is increasingly ever distant from the general practitioner.  I am absolutely providing the best care that I know how and I know this helps patients.  I truly don't care if others don't wish to provide this or some doctors want to blindly follow AAHA, AVMA, and the dental college.  I just don't want to be told how to practice.  I did 180+ hours of CE in the past 4 years or so and am an ABVP diplomate.  I am open to change, being wrong, and progress.  That is not what this is.  I find immense irony that the dental college could be so adamantly against something that could help dental care when there is so much untreated dental disease.  They are against it without parsing the vast difference in how and who provides a NAD and for most of them without even seeing one.  They could be on the forefront of this in defining  the parameters and setting standards,

For opponents of this who wish to be vocal, please actually see one of these procedures by a trained dental technician.  Make your opinion informed.  For Debbie, your comment is what those of us in support of NAD are talking about.  The animal you reference "went" elsewhere for NAD.  If a similar animal was treated by an animal dental technician care under direction of the animals doctor, in the hospital, they may have noted the loose teeth and recommended against NAD.

I also resent that I was not contacted and at least warned.  AAHA knows from inspections who does this.   They made their choice that alliance with the dental college was more important than us and the other clinics that use NAD in their practices.  Once this standard is in force hospitals like ours will either leave AAHA or stop doing NAD.  The caseload at groomers and pet stores with substandard procedures and no oversight will increase.  There will be no increase in anesthesia dentals.  There is no positive outcome for this standard.  

I for one will no longer be AAHA after this becomes a mandatory standard.  

Shelley R. Epstein
Shelley R. EpsteinUnited States
9/11/2013 5:07:08 AM #

I’ve been associated with AAHA in one way or another almost continuously since 1981, when I was our vet school class rep to AAHA. Fast forward to 2013, and my practice is gearing up for our accreditation reevaluation due this fall.

My staff and I share a commitment to AAHA and the high standards set by our organization. We are proud to be able to tell our colleagues that our hospital is one of the few AAHA-accredited practices in our (small) state. We leverage our AAHA accreditation in explaining our higher fees to clients, explaining how these standards, while costing us more, enable us to deliver the highest level of care to their pets.

And because we want the best care for our patients, we also do non-anesthetic dentals (NADs).

So you can see the conundrum that has been created in a practice such as ours- and apparently in many others- by the new AAHA mandate forbidding NADs.

About 5 years ago, my classmate and dear friend from vet school started telling me about Pet Dental Services (PDS), the company that was doing NADs at her practice. She really wanted me to consider offering this service and could think of nothing bad to say about them.  She had a strong anesthetic dental service in her practice and felt that the PDS dentals offered a logical compliment to her anesthetic dentals.

When her PDS technician moved to my area, my friend once again contacted me and advised me to not let this opportunity slip by.  Of course, having heard only bad things about NADs and associating them with the catastrophes created by certain groomers in our area, I was very reluctant to pursue her advice. However, she put me in contact with one of the owners of the company, Josh, who spent over an hour on the phone answering my many questions. We do a lot of dentistry at our practice, and I wanted to make sure that we would not be substituting lower quality dental cleanings for our anesthetic cleanings, and that their procedures were safe. Moreover, I had no concept of how one could comfortably restrain a dog or cat and do a thorough cleaning at the same time.

Josh answered all of my questions, including those that probed, in depth, a clinical trial he had just completed with Dr. Jan Bellows. [I believe this study just came out this week or will be out next week.] He assured me that his technicians were highly trained, having completed a minimum of 2 years apprenticeship and having passed an 800-question exam. They knew how to chart mouths and look for oral/dental pathology, often better than veterinarians. He assured me that rumors of aspiration of calculus and other horror stories did not occur with their dentals due to their techniques, training and various levels of patient screening.

Intrigued but still a bit leery, we invited a PDS technician to perform a cleaning on a dog belonging to one of my vets. We were impressed- by her handling, by her ability to thoroughly clean the entire mouth using what seemed like all 10 of her fingers independently- cleaning all tooth surfaces and subgingivally- and polishing…and when she finished, the dog jumped up, faced her, smiling and wagging its tail.

Fast-forward to now: We’ve been working with PDS for 1.5 years. All patients are first seen by one of our vets. Some of these are new patients to our hospital, as we are the only one in our region offering this service. Our vets screen the patients for mild tartar, 2mm or less pockets (via probing) and lack of other oral problems as well as a temperament that is amenable to someone working in their mouths. Many patients (most) don’t pass this first screening level. Quite often, the patient that is new to our hospital actually needs an anesthetic cleaning, and the client, being impressed with our assessment (and presumably our staff, hospital, etc.) opts to have us do the procedure.

PDS has the client fill out a form so the technician can make sure there are no concerns that would disqualify the pet from the dental. For example, if a dog has a back or neck problem, then technician will not want to risk injuring the dog during restraint. We had one such disqualification recently.

Their technician then performs the oral exam. Because of their skills in being able to visualize the entire dentition in the awake dog/cat, these techs quite often find lesions that we missed. When this occurs, the tech brings this to a doctor’s attention immediately, and we then decide if we want the tech to continue with the cleaning or stop and schedule an anesthetic dental. We’ve increased our number of anesthetic dentals since using PDS.  Moreover, in the cases in which we’ve had the tech proceed with the cleaning and we address the identified issue with anesthesia, we’ve seen how thorough their procedures have been.

The client acceptance has been overwhelming. Many of our clients want to start good oral care when their pets are young but the tartar gets ahead of them. When we detect early tartar and up to 2mm pockets, the clients are thrilled that this can be simply addressed with the PDS dentals. Since our cheapest anesthetic dentals- those that entail routine cleaning and are 25 minutes or shorter- cost over twice as much as the NADs and involve the risks of anesthesia, clients are much happier with this option.  Clients also are thrilled that sometimes our expensive anesthetic dental procedures can be followed up with non-anesthetic cleanings for a while. In fact, we’ve heard countless times from clients how grateful they are to us for offering this service. [A note about anesthetic safety: We have a LVT monitor 7 parameters during anesthesia. At least a few times a year, we detect arrhythmias, for example, in the patient anesthetized for dental work. Yes, anesthesia introduces risks that are not present in the awake patient.]

So you can see the dilemma we’re facing. AAHA has decided, without asking its members if any of us are participating in non-anesthetic dentistry and what our experiences are, to mandate that this vital service not be allowed. We practitioners are now in a position to either discontinue a service that we feel is safe and effective because it’s being done properly, a service that has garnered high client satisfaction rates and expanded the reach of our dental care program, a service that now has a clinical trial to support it; or relinquish our AAHA accreditation. We don’t understand why this one standard, without discussion among members, has been elevated to the level of a mandate when, as pointed out, tooth extraction without radiographs are not a mandatory disqualifying standard.

And given the recent/pending peer-reviewed clinical trial on NAD, the use of NAD has a higher level of evidence to support it than does the mandate which is purely based on expert opinion with no supporting clinical trial.

I’ve been asked countless times by my staff what I am going to do: Give up NADs or relinquish our AAHA accreditation. I have answered them with “neither.” I have every hope that AAHA, as a member-driven organization, will listen to concerns and experiences of its members who utilize NADs and reconsider their stance. In my opinion, now that AAHA has discovered the prevalence of NADs among their members, a new set of standards governing the use of non-anesthetic dentals in practice would be a much more prudent option.





jessica
jessicaUnited States
9/11/2013 5:51:13 PM #

AAHA- You are all forgetting about prevention in between anesthetic dentals with radiographs, are you suggesting owners are to put a pet under every 3-6 months for a dental cleaning ? Are you suggesting that there is no alternative available to pets for routine cleanings and surgery is the only option? Have you ever taken a child to the dentist for a cleaning? Or do you believe pediatric dentistry is impossible? What do you think parents would say if you told them that every time their child needed a routine cleaning we needed to place them under general anesthesia? I'm pretty sure a large portion of the population would be walking around with horrific dental disease. This is really a simple service and in no way has Pet Dental Services suggested they replace anesthetic dentals with dental radiographs. The entire model for Pet Dental Services is an adjunct therapy in between routine anesthetic dentals, a compliment to an already existing dental care program. This is an ideal procedure for young pets with healthy gingiva and minor calculus, for pets who have recently had anesthetic dentals with radiographs that need a routine cleaning and for pets with pre-existing medical conditions that a specialist would conclude a poor candidate for general anesthesia.

Please explain to me why you are not mandating dental radiographs?? That is the real shame. We all know how risky it is to conduct extractions without dental radiographs, but yet you are still accrediting hospitals that do not have them. That seems un-expectable to me. Something seems very strange about this mandate and it appears there is a large group that agrees. We are all waiting for answers.

Eric Belnap DVM
Eric Belnap DVMUnited States
9/18/2013 5:37:58 PM #


My hospital has been AAHA accredited for over 25 years.  Mandating that dental cleanings be performed only under anesthesia has surprised and disappointed both me and my partners.  I perform most of the anesthetic dental procedures in our hospital and am able to do more advanced procedures than most general practices.  We have great high-speed equipment, digital radiography and perform both periodontic and endodontic procedures.  We carefully select pets for non-anesthetic dentals, as not all pets are candidates.  The dental technicians that perform the non-anesthetic dentals are professional, well-trained, patient and thorough.  They also know this procedure is very beneficial for patients and clients, provides another forum for client education and increases preventive dental compliance.  I would respectfully request that AAHA reconsider this very broad mandate and formulate guidelines and voluntary standards that will benefit our profession rather than hinder it.  


James Barton DVM
James Barton DVMUnited States
9/18/2013 5:47:17 PM #

Our hospital has been an AAHA affiliated practice for over 25 years.  We feel that mandating that all dentals be performed under anesthesia is the wrong approach.  When we were first contacted about offering this service to our clients, we were very skeptical.  But instead of saying “no-way,” we agreed to see the very skilled dental technician perform this procedure on several of our employee’s pets.  We were absolutely amazed at how smooth all the cleanings went and what a completely thorough job the technician did – not only cleaning and polishing all surfaces of the teeth, but also probing, charting and looking for pathology – and the pets were not stressed, were very compliant and awake and happy when the technician was done.  After offering this procedure for 2 years, we KNOW that this is a step forward in veterinary dental care.  We are able to prevent some of the nasty, tarter-filled mouths in dogs while their teeth are in good shape, instead of having to do multiple extractions later.  We have been able to convince clients, after performing a non-anesthetic dental, that their pet will need x-rays and possibly extractions, once they see the teeth clean.  It also allows clients to plan for their pet’s anesthetic dental when it best fits their budget.  We carefully screen each patient for applicability and temperament and only recommend NAD’s for those pets that would benefit from it.

We have always strived to maintain the highest AAHA standards and will continue to do so regardless of this mandate.  We will also continue to offer non-anesthetic dentals to our patients.  Non-anesthetic dentals are professionally done procedures by extremely well-trained technicians under the supervision of our veterinary staff.  We have had no problems. We are offering better dental care and are achieving better compliance than we have ever had.  NAD’s are NOT sub-standard dental care;  they are progressive dental care.  We have not mislead our clients, nor are we doing this to boost revenue.  Our veterinary staff is honest, ethical, dedicated, caring and responsible.  We do not perform or allow procedures that are not in the best interests of the client and the patient.  If the group of veterinarians who chose to mandate anesthetic dentals only would actually see the procedure performed ONCE by a trained dental technician, they would see the value that non-anesthetic dental procedures will ADD to a preventive dental program.  We would certainly welcome guidelines and standards, but not a mandate regarding this procedure.

Pam Bergeron, RVT, CVPM
Pam Bergeron, RVT, CVPMUnited States
9/18/2013 6:25:22 PM #

I was also a skeptic when I heard about non-anesthetic dentals.  Surely, no animal would allow anyone to clean its teeth awake.  After watching the Animal Dental Care technician clean our pets' teeth - our staff's not-so-nice cats and dogs - I was convinced.  I have always been a technician (patient advocate) first and practice manager second. Adding this service to our practice allows me to be both.  Our patients are getting the best care available and our practice has benefited by increasing client satisfaction and dental compliance as well as allowing our doctors and staff to provide better client education and patient care.

Mandating that all dental cleanings be performed under anesthesia is to the detriment of the pets.  Most everyone in our profession has worked hard over the years to increase dental compliance, but usually by small increments. Now we have another tool that allows us to make some real progress towards better dental care.  It's not for everyone (practices, clients or pets) but for those practices that have made a real effort to check out non-anesthetic dental procedures for safety, quality and applicability, it has definitely added value to preventive dental care.

We are all hoping we don't have to choose between AAHA and NAD's because we all want the same thing - quality patient care.  Guidelines, minimum standards and/or voluntary standards for non-anesthetic dental procedures would be much more appropriate, especially in light of not having dental radiographs as a mandated standard.  Regardless, we will continue to practice veterinary medicine to the highest standards.

Dr Bo
Dr BoUnited States
9/20/2013 1:53:08 PM #

There is lots of misinformation and rhetoric being passed around about this issue.  Where is the evidence based medicine that you are basing your decisions on.  We too are a long standing AAHA hospital that thoroughly investigated the option of NAD.  I for one was very skeptical but was also completely convinced of the value of NAD.  The ABVD and the AAHA statements seem to be referring to groomer dentals.  I would request the AAHA take a leadership role in this process rather than making a decision which it says is evidence based. Anecdotes are not evidence!!!.  It would seem wise to us (with a combined 82 years of practice) for the AAHA to table this dramatic change in position and partners with ABVD and set some standards and get some evidence to base their decisions on.  There are at least two very reputable animal dental care companies who I am confident would be more than willing to participate.  We are very pleased to offer NAD as one component of veterinary dental care.  It is a great service which can be used properly.   When was the last time anyone of you had anesthesia for your routine dental care.  Did you aspirate??  Did the technician not probe your teeth???  Did they skip the subgingival scaling because it was too painful and you were awake???  I think not!!!.  We all too often just keep hanging dogs by their feet to do abdominal surgeries.  It is time for a good change.  Don't ignore the great number of well established good docs who are willing to give up their accreditation because they believe with good reason and experience that NAD are a viable procedure.  Table the decision and get some solid evidence from reputable sources.  

Alison
AlisonUnited States
9/22/2013 1:07:58 PM #

I am an associate at an AAHA hospital and was also skeptical about NADs when we first met with Pet Dental Services.  We do a lot of dentistry and I spent a lot of time upgrading our dental program when began as a new associate.  Upon the upgrade, we started performing dental radiographs for all extractions and made a tremendous upgrade to our equipment.  Quality dentistry is very important to me so I really wasn't sure how NADs would fit in and if they would be up to our hospital's standards.  
Over the time that Pet Dental Services (PDS) technicians have been coming to our hospital, I have seen more owners agree to dental care for their pets because of the decreased cost of the procedure.  Interestingly, however, if their pet "fails" a NAD, they are quick to sign up for an anesthetic procedure because the PDS technicians has been able to really encourage them to follow through on the dental care.  The technicians are able to identify lesions and pathologies that I am just not able to find or address in my office during an annual examination.  
I feel that we are doing more anesthetic procedures because of the PDS technicians recommendations.  Maintaining oral health care has become more "doable" for our clients after anesthetic procedures because they are able to get a NAD in between anesthetic procedures.  They are realizing how important oral health care is and how much more accessible it can be when they do not have the expense and worry of having to anesthetize their pet every 6 months.
I was very surprised that AAHA made anesthesia a mandatory standard when dental radiographs are not mandatory for extractions.  I can't imagine performing any type of extraction (other than the loosest of teeth) without the benefit of dental radiographs.  In my opinion, AAHA has mandated the wrong standard.  
Instead of a mandate that all dentistry is done with anesthesia, why not mandate the quality/type of dentistry that is performed (with and without anesthesia)?  IA reputable NAD service has technicians that are much better trained in dentistry than many veterinarians are coming out of vet school.  I am a relatively recent graduate and had no clinical dentistry training - having to learn through CE, reading on VIN, and wet labs.  I think the PDS technicians I have worked with could actually have taught me a lot about oral pathology and dental care when I was a new graduate.
I am not sure why hospitals are being asked to choose between NAD and AAHA accreditation. It shouldn't be an either or situation. It is very upsetting to me, as I find that AAHA helps our hospital to keep up with the highest standard of care.  It will be a very sad day to see our hospital part ways with AAHA because of the inability to find a middle ground - ie, standards for a service that is not going to go away just because of AAHA's most recent mandate.  

AAHA
AAHAUnited States
9/24/2013 9:08:39 AM #

Thank you for your comments. We appreciate feedback from our members, and all of your comments have been forwarded to AAHA leadership. At this time, we will be closing comments on this issue. If you would still like to share your perspective, please email aahapresident@aahanet.org. Thank you!

--The AAHA team

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