Once again the profession is under attack from accusations of “over-treatment” and profiteering. The sad little TV exposé programme (ITV’s Tonight) will add some fuel to the fire.
Occasionally clients faced with a large bill will raise the issue of practice profits – as they have always done. Concerns over the economic climate may increase the frequency of attempts by clients to “negotiate” bills.
There may be a tiny, very tiny, minority of the profession that may exploit the trust of their patients and clients; a far greater problem, however, is that part of the profession which is undertreating. Undertreating dental disease in particular.
How can I make such a sweeping statement? By looking at the figures: 80% of our small animal patients over the age of three need dental treatment. If your practice had 80% of its patients infected with fleas, or had mammary tumours, or arthritis, or heart failure and you were doing little about it, you would have grave concerns for the care that your patients were receiving. Why is it any different for dental disease?
Given that 80% of our patients over the age of three need dental treatment, one would expect dentistry to form a significant proportion of practice income.
In the majority of companion practices in the USA, dentistry represents less than 5% of income, and there is no reason to assume the UK would be any different. This can only mean that some vets are not diagnosing the problem, are not offering treatment, are unable to persuade owners to agree to treatment, or are grossly undercharging. I don’t think that undercharging to this extent is the reason.
Given that owners readily agree to chemotherapy, hip replacements, extensive investigations of skin problems, on-going cardiac therapies and the like, I have no doubts in the ability of the profession to be able to convince owners of the benefits of treatment. Therefore, we are either not diagnosing, or we are failing to offer treatment for dental disease.
The reason for our failure to deliver dental care has been described by Norman Johnston as a “conspiracy of inaction” and is composed of many facets, the most important of which is that only 4% of small animal dental patients are presented by their owners. In other words, 96% of cases require active investigation by the clinician to diagnose and initiate treatment.
Bluntly, vets just ain’t “lifting the lip” – or if they are, they are ignoring the findings (Figures 1-4). It is not that our patients don’t have oral pain, it is simply that they don’t show it in as demonstrable a way as a dog walking lame.
So if vets are “lifting the lip”, why would they then fail to offer treatment, or choose to utter the stock response, “It isn’t too bad – we’ll sort it out in another week/month/year”? I suspect a lot lies in the vicious cycle of poor training at veterinary school, leading to frustration at poor results achieved in practice (compounded by often poor equipment), then fear from past bad experiences.
This means that dentals are not booked in, adding to a lack of experience and familiarity, leading to yet more poor results. Exacerbating this downward spiral is the fact that most practices don’t have separate dental theatres, so dentals are carried out after the clean surgery (further enforcing the stereotype of dentistry as 2nd class surgery).
The surgeons are inevitably more tired and have the added pressure of the afternoon’s batch of consultations looming ever nearer. Suitably trained nurses do carry out an excellent job in dental care. However, I always feel that having a nurse does not absolve the vets from being able to perform the task. How many vets would say, “I can’t take blood samples – but I have a nurse who can”? Of course, dental extractions are also legally the preserve of the vet.
Conspiracy of inaction
The conspiracy of inaction regarding veterinary dentistry most importantly represents a huge welfare issue for our patients but it also represents a huge loss of potential income.
There are plenty of things that can be done to rectify the situation. I’d love to start with the veterinary schools taking dentistry seriously. It is somewhat bizarre, given the frequency of dental disease, that there is not a single full-time permanent member of any UK veterinary academic institution devoted to the subject.
New graduates won’t be expected to pin and plate on Day 1, but you can be pretty sure that a few dentals will be thrown at them. Why aren’t the paying customers, the students, demanding training proportionate to the extent of the disease?
In the meantime we have to rely on post-graduate training. Dentalvets.co.uk, Improve, EVDS and BVDA all run courses. In the courses I run for Improve I try to break down the barriers to providing dental care. We take one of the worst possible experiences: accidentally “popping” an eyeball by slipping with an elevator when extracting a molar. On my courses, everyone does this on a cadaver specimen – so that they can avoid doing it in a real life patient.
We look at how the use of proper equipment and techniques can minimise the chances of accidents. As importantly, it can change procedures from being frightening to simple technical challenges. But where is the money for these courses and new equipment going to come from? The answer to this lies in the simple statement that 80% of your patients over the age of three need dental treatment. We spend many thousands on ultrasound machines – but do 80% of your patients need an ultrasound today?
Realistically, three extra cases per week is probably a gross under-estimate of the increased workload that having good equipment will bring to your practice, but even at this level the financial benefits of investing in good dental equipment are clear.
A more unquantifiable benefit, but one of greater importance, is the improved welfare of your patients. The increased job satisfaction and the decreased stress of the practice team from having proper training and equipment are also important, but difficult to quantify.
In conclusion, I urge everyone to “lift the lip”, to act on their findings and to invest in good dental training and equipment. This way veterinary dentistry can become fun, rather than a fear, and Cinderella’s fairy godmother will have achieved her aim.
A stitch (and a cut) in time…
This cat was admitted for a routine scale and polish. The observant nurse noted a small lesion at the base of the tongue.
Histologically, the lesion was identified as an early squamous cell carcinoma.
The margins of the excisional biopsy were clear. Three years later the cat is happy and enjoying life with no signs of recurrence. If the dental had not been carried out the lesion would not have been seen, diagnosed or removed.
Dentistry is not just about periodontal disease!
An ethical case
The owners presented this cat having had an “oral clearance” elsewhere for the treatment of feline chronic gingivo stomatitis (FCGS).
As can be clearly seen, root remnants were left in place. Whilst these remain FCGS will certainly continue – if not worsen. How do you break the news to the owner?
Carrying out human dental extractions without radiography could be considered negligent. Veterinary dental units are highly affordable and can save your bacon time and time again.
