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Case Studies

Dental Case Studies Typically Seen in General Practice
General dentistry in small animal practice is hard work, followed by more hard work. It requires a committed group of people inside the dental portion of the practice and an entire hospital that believes in the philosophy of excellent oral health and its contribution to longer, healthier and pain-free lives.

Communication is critical to operate a dental profit center. When things go right, effective communication has occurred. When the day is substandard, dysfunctional communication is most likely the reason. Communication must exist among the dental operatory, the rest of the hospital, the clients and even the patients.

This series of case studies gives your team some ideas about what they are doing well and how they can do better. Have them review the cases and write their answers as to how they would handle each one. Discuss the answers with all staff by email, during rounds or at a staff meeting.

If the staff answers to these cases are similar, then dentistry is probably going well at your hospital; if there are discrepancies, you need to do some consensus-building, and create a strategic plan and protocols before you proceed further. In essence, a hospital cannot simply say dentistry is going to be a profit center without investing in CE time and training, along with the proper equipment.

Finally, none of the previous will work by itself; communication is the glue that will allow your hospital to include dentistry as a profit center at your location.

To understand where your hospital or clinic falls in the scheme of communication, have everyone answer the following case studies independently. These are routine cases seen in an average day at a general hospital that follows the 2013 AAHA Dental Care Guidelines for Dogs and Cats. Hopefully, they will illustrate the conundrums and complications of routine, non-specialty day-to-day dentistry.

Case 1

The first patient of the day had a beautiful mouth at her awake oral examination. Riley is a golden retriever who gets her teeth charted, cleaned and X-rayed every year on her birthday. Her teeth are brushed daily and have been starting at 12 weeks of age. She is so easy to work with, she can almost place her own IV catheter.
After Riley is sleeping under a general anesthesia and her mouth is charted, a large slab fracture is found on the lingual surface of her mandibular molar. This could not be seen at an awake exam because the entire coronal surface from the buccal side appeared normal. She did not show any resistance to her awake examination, so you did not notice the open pulp exposure and painful tooth.
  1. What are your expectations for this procedure?
  2. How much time will it take?
  3. What type of treatment plan will be given to the client?
  4. Now what do you do?
  5. How do you explain the fractured tooth to the client?
  6. What is the impact of exposed pulp tissue on local and systemic health?
  7. What treatment options are available to fix the tooth? How would you discuss the pros and cons of each option offered?
  8. What can your hospital do to fix the pathology?
  9. How do you handle any timing changes that must be made to accommodate fixing the tooth on the same day?

Case 2

A cat that has had its teeth cleaned while awake (awake, nonanesthetic dental scrapings) every 3 to 6 months for the past 3 years is in to have her teeth cleaned under anesthesia. The owner is frightened about general anesthesia because she has been told that Sandy’s breed is sensitive to it. The client is coming to you because her cat has been drooling, and she cannot get the cat in to her regular veterinarian. She found you on the Internet because you are a cat-friendly practice.

Sandy will not allow you to touch her face and prefers that you keep away from the rest of her body also. She is fully equipped with front claws and does not hesitate to use them during the awake, physical examination. You suspect she is suffering from white coat syndrome because after you tried low-stress restraint with a towel, you ended up scratched and bleeding. Meanwhile, your patient is hiding in a cabinet, growling and hissing.

On the day of the procedure, the client has elected to stay so she can review X-rays with you while Sandy is sleeping. On asleep and X-ray examination, her mouth is found to contain 24 tooth resorptions in various stages of progression.
  1. How much time do you allow for this appointment?
  2. What do you charge for it?
  3. Explain your dental, anesthesia (include monitoring systems and fluids), and nursing-care protocols in a way that comforts the apprehensive client.
  4. The client has decided to go ahead with anesthesia and would like to do it that day because Sandy is already at your hospital.
  5. How would you accommodate that?
  6. If you couldn’t accommodate it, how would you explain it so the client understood it was in Sandy’s best interest to come back?
  7. How do you explain this disease to the client?
  8. How do you discuss the pain of the disease without making the client feel ashamed that she was having her cat’s very painful teeth scraped while being held down in a cat straitjacket?
  9. What do you say if she asks you about the standard of care that her pet had been receiving?
  10. Do you call her veterinarian and talk to him about the procedure? What do you say?
  11. What is your pain-management strategy for this patient?
  12. How do you explain the necessity of an overnight stay (or more) in a patient that needs anti-pain medications to have a comfortable recovery?
  13. You successfully removed all the tooth resorptions, and the client has switched over to you to be the primary care veterinarian.
  14. She asks you to call and get her old records. Do you tell her past primary care veterinarian what happened?
  15. What accommodations will you make in the future to make certain Sandy is less stressed coming to her appointments so you can examine her without placing her in a body bag or a net?

Case 3

You are doing an awake examination on a rather pleasant orange cat named Melvin and you notice a chipped upper canine tooth. By the way, Melvin had broken his leg several years ago when he was a kitten and you saw him for that too. At the time, you were amazed how nice he was and that he didn’t seem in pain. Today he is happy to have his chin scratched and is purring throughout the appointment.
  1. What do you tell the owner?
  2. How do you tell if there is bacterial leakage into the pulp chamber?
  3. If there is leakage, what are the options available at your clinic? If there is no leakage, what does the owner need to do?
  4. How soon do you need to get him in for X-rays?
  5. How will you plan for treatment time for his examination under anesthesia?
  6. If he needs to have a root canal or the tooth extracted, will you be able to do it the same day as the examination under anesthesia?

Case 4

A very sweet Cavalier King Charles Spaniel named Brother Peter is in to have two eyelid tumors removed. As he is checked in, his owner asks if he can also have his teeth cleaned.
You chart, X-ray and clean his teeth. Upon X-ray review, you find two unerupted lower premolars and two incisor teeth fractured below the gum line. Additionally, he has a tooth that is more yellowed and has a large pulp chamber compared to his other teeth. Peter’s family was thinking he was getting his teeth cleaned just because he was already under anesthesia.
  1. What do you say?
  2. How do you accommodate it?
  3. How do you explain the X-ray findings to them?
  4. What do you do if they don’t want to extract the teeth?
  5. What if you were unable to reach the clients and you went ahead and extracted the teeth and now they are angry? Go through the steps you would take.
  6. How could your hospital prevent such an occurrence from happening again?

These case studies will help illustrate the importance of collaboration and communication both within your hospital and with your clients. Dogs usually have 42 adult teeth and cats have 30. To give their teeth the attention they deserve, you must evaluate your patient’s mouth under general anesthesia, taking the time to probe, chart and X-ray each tooth in order to make an appropriate medical plan.

How would you solve these cases?

Tell us how your team worked through these cases and what improvements resulted. Send your comments to aahapreventivecare@aaha.org, and AAHA will publish them for the profession.
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