Pet Restraint

One of the toughest things I encounter on a daily basis is the realization of how much a lot of my patients really don't like me. In fact I often tell people looking to become veterinarians that if their major motivator is a love for animals, they should think about owning a boarding facility or being zookeepers. I say that because more often than not the animals we are dealing with want nothing to do with us in the exam room. Even my own cat will hiss and get his fur on end in one of our exam rooms and at home he's an absolute love.

Pet aren't in my office, however, for me to pet and love on them. They're there because I have a very specialized set of skills. A set of skills that allow me in less than half an hour to use my ears, hands, eyes and often nose to tell you whether or not your pet is healthy. Unfortunately, even for the most skilled veterinarian the examination part of that half hour requires the patient to be restrained. Restraint is often the most difficult part of the visit for pet owners to deal with. Many times they will try to comfort their pet during restraint or some owners will even try to do the restraining themselves. Over the next four short paragraphs I will try to explain why restraint is important and why you should step back and let us do what we're trained to do.

It's dangerous for you. Hospital and court documents are full of stories of well intentioned owners whose pet's would have never bit them otherwise who were injured while trying to comfort or restrain their pets and subsequently had to sue their veterinarian. Notice I said had to sue their vet. A single cat bite in an otherwise healthy person can lead to an infection that requires a hospital stay and intravenous antibiotics. it's not unusual for treatment like this to cost tens of thousands of dollars. If you have insurance, they will sue me. If you don't, you will have to sue me just to cover your medical bills. I understand that and wouldn't blame you but if I can prevent it simply by not having you hold your pet or touch it while it is being restrained, I will. the last thing I want is for you to get hurt and possibly seriously ill from something I could have prevented by being a little more assertive.

It's dangerous for your pet. You know your dog or cat better than anyone. I never forget that, in fact it's why I ask you to bring them in every year and not have someone else do it for you. To me, you are the most important source of information about how your pet is doing. What you might not know about your pet is how they are going to respond when I inject them with a vaccine or apply gentle pressure to that really painful loop of intestine I found on physical exam. I have seen owners "have to" hold their cats by one leg as they tried to jump off the exam table, needless to say that is not good for the cat and possibly not very good for the owner either. Th bottom line there is, you aren't trained in animal restraint, my staff is. Allowing them to do their jobs makes the exam go faster and allows it to be more thorough. Fortunately, I have never seen an injury to a pet during an exam but much like the paragraph above, if my telling you that I can't allow you to restrain your pet during my physical exam is what it takes to prevent an injury, that's what I'm going to do.

It's dangerous for me. I make a living with my hands. I need them to do my job. The number one place I'm going to be bitten by a pet is on the hand. If I get a bad enough bite or an infection from a bite that costs me the use of one of my hands, my career is over. You might know your pet inside and out but you don't know what I'm going to do next. My staff does. On any given day we will examine between fifteen and thirty pets together. Sometimes we are examining pets together in the early hours of the morning when no one is quite awake. For safety and to offer your pet the best care we have to get it right every time. To do that, we practice together. We don't practice until we get it right, we practice until we can't get it wrong. If I'm having someone I haven't worked and practiced with hold a pet during an exam, there are things that aren't are going to happen. The most important is that the pet is not going to get as thorough an exam as it deserves and there are certain things that I will not even attempt such as a full ocular exam, a complete oral exam and I may not look as thoroughly at the ears. I will probably not be doing a rectal exam and in some cases will have to even skip the temperature. That's not great medicine. Oddly enough, we don't have a charge built in for an exam limited by having the owner hold the pet. You're still going to pay for the full exam I would have performed if my staff was holding your pet. You just won't get that exam.

Finally, it is below the standard of care for a veterinarian to have you restrain your pet during a physical exam. In Setting the Bar Higher I talked about how there are not many actual defined standards fo care in veterinary medicine. This is actually one fairly universally defined standard. If something happens in an exam room and a pet or owner is injured while the owner is restraining the pet, that is my fault because allowing an owner to restrain the pet for examination or treatment is below the standard of care. I try to never practice below the standard of care, that is a commitment I have made to myself and to your pet and you. Often that is difficult and the standard of care is open to interpretation. When I have a set standard that I can adhere to, I will.

Many of the people who read this blog have been in situations where I might have let you hold your pet for something, I'm not perfect but maybe you'll be more understanding now when I ask you to give us a little more room to do our jobs better.

 

 

Fun Dentistry Case

Here's a fun dentistry case I saw recently and wanted to share with you. This case really illustrates what you are not getting if your vet is doing "dentals" without taking x rays.

This puppy was "missing" the tooth just behind his canine during a neuter visit. I circled where the tooth should be.

 We know here at Riverside that missing teeth aren't confirmed to be missing until we have a radiograph or x ray to confirm. In this case the tooth was there, it was just taking a snooze.

That tooth is never going to break through the gumline. The problem with that is that the sac the tooth lives in until eruption will continue to make fluid. This will lead to a dentigerous cyst. Here is some third party information about dentigerous cysts. Dentigerous cyst

We made a little incision in the gumline over where the tooth should be and there it was!

The tooth removed easily enough.

We removed the tooth and the fluid producing lining. Of course we always make sure we got everything by taking a post extraction x ray.

Everything looks good, so we closed this up with just a few absorbable sutures and sent the little pup home. Actually, we sent him home after repeating the exact same surgery on the opposite side. He had two napping teeth in his mouth. That's two chances to form a cyst that could have resulted in a very complicated jaw fracture.

The take away message is: if your pet has been diagnosed with missing teeth but you don't have x ray confirmation that they are actually missing, you should schedule a visit with a veterinarian who has x ray capabilities right away. Please don't let your pet end up here as a cautionary tale instead of an educational one.

Warning: Heath has been to more dental continuing education!

This will be my 12th blog about dentistry in veterinary medicine. Caution: run on sentence ahead. There is so much that I want to illustrate for you and teach you about what goes on in your pet's mouth and what you and I can do about it together that I could and just might spend the rest of my life writing and talking about it. What I am going to do today is break down the top 7 reasons people aren't aware of how big a deal this really is. I will try to provide external third party links where applicable.

1. Veterinary schools do little or often nothing to prepare veterinarians for dentistry. Today during a lecture a board certified veterinary dentist stood in front of a group of veterinarians, technicians and practice managers and said, "When I graduated veterinary school my dentistry education could be summed up in one sentence. Dogs and cats have teeth." Not a lot has changed since then: the majority of veterinarians out there don't know how to recognize and treat many dental problems. Unless your vet has had extensive training in dentistry after graduation, they might be missing the early more easily treated stages of periodontal disease.

http://www.dentalvet.com/vets/basicdentistry/are_you_into_dentistry.htm

2. Periodontal disease is caused by invisible bacterial laden plaque; this gets under the gums and causes inflammation. The body responds by walling it off and breaking down the bone and tissue attachments of the tooth. In short, the bacteria cause inflammation, the body causes bone loss. This plaque is not the same thing as the calculus or dark matter on the tooth. This fact is missed even by really great vets that I know personally. If we as vets go in and just remove the major calculus off for you, it does nothing for your pet's periodontal disease because the periodontal disease is caused by plaque which is different than calculus. We need to remove the plaque and then start preventing it. 

http://www.dentalvet.com/vets/periodontics/periodontal_disease.htm

3. Plaque is a bio-film. This is a liquid substrate of symbiotically existing bacteria. These bacteria, when compared to their free living counterparts, are up to 1,500 times more anti-biotic resistant and up to 500,000 times more resistant to antiseptics. This is why the infection caused by plaque has to be dealt with by physically removing the plaque (surgically) and can't be dealt with medically.

http://en.wikipedia.org/wiki/Dental_plaque

4. Plaque starts to form within 24 hours after a complete cleaning. This is why you and I brush our teeth and floss after we see the dentist. If your pet has not had any extractions we will start home care the day you pick him or her up after the procedure. If they have incisions in their mouths we will have to wait 2 weeks to start the major preventative measures. This puts us two weeks behind the game. If we don't do any home care, your pet will be re-infected in less than 6 months. Will be, not might be. WILL be.

5. Over 90% of dogs and cats under one year of age have some level of gingivitis and plaque build up. This means that nearly all of our patients should really be having their first dental cleaning at one year of age.

6. Many people will say that their pet can't have anesthesia or dental work because they are old or have diseases like diabetes, renal disease, cancer- the list is endless. If your pet is very old or has an ongoing illness it NEEDS to have proper dental care. Yes the anesthesia needs to be performed by a well trained and attentive staff but it is necessary to have a healthy mouth if we are going to manage other chronic diseases or stave off cognitive decline. Remember, your pet's head and mouth are attached to the rest of the body and the disease in the head and mouth affect the rest of the body as well. If we removed the gingiva from your pet's mouth and spread it out on a table it would be about the size of the top of their head. If you came home and your pet had an inflamed and infected wound covering the entire top of their head you would bring them in and ask me to treat it right? Why is it so different in the mouth?

7. Veterinary dentistry is super expensive. It is cost prohibitive to many of my clients and if we are going to do it right we should be doing it at least every year. My family has five pets, 6 if my wife gets to claim me and 8 if we add the kids. If we had to pay for dental care for every one of them at full cost we would be spending, at current prices, at least $1,375.00 in just dental care every year! Here's the tough part; for what we do at Riverside Veterinary Care, we are super economically priced. Other vet clinics doing comparable work in similar areas are charging between $500-600/pet for that level of service. We collectively decided we wanted to increase the number of pets we could help and were willing to get by on a little less income to do so. And it's still really expensive! Pet insurance can help with that. Check out this site and seriously think about getting insurance for your little furry one:

http://trupanion.com/ppc/homepage?gclid=CNrboJzuxbMCFad_QgodEGoA4Q

In summary, oral health is not just important, it is vital to maintaining good overall health. Evidence shows us that if we maintain good oral health your pet will live up to 15% longer. How do you put a price on that?

 

 

 

No title today.

One of the quiet- but important- parts of what I consider to be my mission in this life is to not stand idly by while seeing the truth others "have spoken twisted by naves to make a trap for fools." As a result I often find myself responding to some article or loose expertise on subjects like health care, science and the like. I try to be diplomatic and informative, but honestly, there is a fair amount of anger and disdain involved. Probably, this is due to my understanding the limits of the system being criticized, as well as my repulsion to the idea that something with even less evidence than we already have could be considered of equal value or that something should be pushed onto the public based on a limited amount of actual science. This happens on all sides of a number of issues and it leaves me tired at night and frustrated a lot during the day.

My most recent tirade was this morning in regards to vaccination. My response to the idea that vaccines cause more harm than good is as follows: Smallpox. Diphtheria. Polio. Tetanus. Yellow Fever. Measles. Rinderpest. Rabies. Rubella. Brucellosis. Parvovirus. Distemper Virus. Panleukopenia Virus. Pertussis. These are all diseases that we in the developed world don't have to think about as much in our human or animal populations due in large part to successful vaccination programs. It's not without problems (you can apply that statement to the whole world, every program ever run and our own lives). Over-vaccination definitely occurs; it is rampant in my world. Vaccine reactions or adverse effects do occur: I've seen eight that required intervention in the roughly 15,000 vaccines I've administered. I've seen at least a dozen cases of vaccine-induced sarcomas as well. Vaccines aren't perfect but to remove one of the most valuable tools that human and animal health have experienced based on a few poor outcomes is to miss the point of medicine. Prevention is always the mission and to do that, we have to take a holistic approach and that has to include vaccines, it has to include filaricidal therapy in drinking water for river blindness and dracunculiasis , it has to include education about clean water and hygiene and it has to include access to a safe and healthy food supply.

I understand the concern: it is serious and it is personal when it happens to you or someone you love. I would never say that the system is perfect and that we don't need further investigation and robust criticism combined with regulation. However, I bristle at the notion that science isn't the best way to work out what we do and don't understand about the Universe and the best way to apply that understanding, however limited it may be. I am repulsed by the idea that- given everything we don't understand- someone would consider it appropriate to apply ideas, models or even treatments without putting them through the same rigorous (although admittedly not perfect) gauntlet that all of the other ideas, models and treatments must endure.

Most likely, this is the same way a quarterback feels on Monday morning watching the sports networks or our men and women in uniform feel when they listen to talking heads go one way or another about military intervention. I think Theodore Roosevelt put it best in his speech Citizenship in a Republic: "It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat."

My ultimate response is to encourage anyone willing to put themselves to task, earn the credentials to give yourself the opportunity to approach these issues with some credibility. Then choose to stand with or against me but until you've earned that right my response is the same, "Thanks for the input but I've got to get back to work."

Meatloaf, papaya and money.

I'm constantly trying to increase the number of people I reach with this blog and some of my other activities. If you enjoy reading A Vet's View please follow me on facebook where I'm posting much more often and I am often not as wordy!

The three title items are the only things I can say I don't like on a regular basis. I'm sure there are others but when ever people ask me to list things I don't like this is what comes to mind. I've written about this topic before but it is such a constant issue for me and my thoughts and position are constantly evolving so I am writing about it again. This is one of those mildly opinionated pieces so it's mostly in the first person because I can only really speak for myself.

It's not that I don't actually like money. I am an American after all: I love money, to a point. What I don't like is when money comes between me and a patient. Actually, that's not entirely true either. I don't like it when money comes between me and my client. A common misconception about veterinary medicine for the public and veterinarians alike is that veterinary medicine is about pets and not people. This is a service we provide to people for their pets. This is a people profession and I love people. I care about your pet, a lot. If you and I have been through an illness, injury or difficult visit chances are you already understand that. I care about your small furry family member and I am one hundred percent invested in what I do. I believe every veterinarian I've ever met feels the same way.

What I might fail to impress on people sometimes is how much I care about them. I love caring for your pets; I spend hours of my time gettting better at it and sharing as much of my time and knowledge as I can. As much as I care about your pet, I care about you more. The relationships we develop with people tend to last longer than most pets live, we are forging relationships with people that may carry through several pet lifetimes. While in some ways that is sad and a difficult thing to put into writing, in many more ways it is my favorite part of the job. I love people. I love being a part of your life. And that is why the money issue is such a frustration to me. When you are standing in my exam room with a pet for a wellness exam or with a sick pet who needs care, there are a lot of things that can and should be done and all of them will cost money. While I understand that for a few of us the finances don't matter, for the vast majority of us every dollar counts. That is true for my family as well. I live in the same world you live in.

I also understand that we will all look at the same thing from different angles. Many of us will put different values on the same service, product or experience. If I had an extra $200,000 I think a tourist trip to space would be well worth the experience; many people think that's stupid. We might both be right. I even have opinions about the value of certain procedures or products offered in veterinary medicine that differ from some of my colleagues. Again, we might all be right.

Here's where I think I lose people quite frequently with the money stuff. We all have predetermined ideas about what things are worth the expense and what things are not. My job is to offer you all of the options that are relevant to your pet's health to give you the best opportunity to make an informed decision. If I think to myself that you won't want to spend money on a treatment or test, and then choose not to offer it to you because I am afraid you'll say no or that you will get the impression that I am only after your money, then I have effectively removed your ability to make an informed decision. What seems even worse to me is that I have made a judgement about you in one way or another. If I decide that you would not be willing or able to spend money on a particular service I am making judgements, whether consciously or not, about your finances, your level of concern for your pet and how you value veterinary medicine. I would effectively be saying, "While some clients can or would afford this level of veterinary medicine for their pet, this client won't or can't." That's not fair. So my job is to offer the best medical advice I can to each and every client I see regardless of my personal beliefs or ideas.

The other important thing to remember is that I offer my professional opinion and medical advice. That's what you pay for and that's what you get, an opinion and advice. Another vet may read your situation completely differently and you might get a different opinion or different advice or both. Remember please that as a profession we veterinarians do care about the relationship we have with you the client; we are always willing to work with you to improve that relationship and the services we offer to you. Just please also remember that while it is our job to offer you every option we have, just because we offer something doesn't mean you have to take it. We make a recommendation and then do our best to work with you to find the best plan that fits your expectations, personal beliefs and lifestyle. The worst thing we could do for you is not let you make the choice by not giving you all of the options.

The Heavy Stuff

My job is inherently emotional. It goes without saying that when you are treating sick pets, things can (and often do) get intense in one direction or another. Sometimes the emotions run hot and we catch the blunt end of the anger stage of grieving. Sometimes emotions run in the sunny direction, often surprisingly. It will never cease to amaze me how frequently we get thank you cards and gifts from clients after their pet does not survive a serious illness or accident. Not that I expect them to be unhappy with us; we show up everyday- sometimes at night- and give one hundred percent of ourselves for one hundred percent of the time we are servicing our clients and their pets. This often includes stepping from one appointment with a seriously ill patient into a vaccine appointment with a new client and their puppy or kitten. That is the topic of this week's A Vet's View.

Actors practice their art by tranforming themselves into different characters to tell a story on stage or screen. It is an art form that involves controlling and expressing human emotion in a believable and realistic manner. The daily life of a veterinarian is not unlike that of an actor. Allow me to tell you about a day I had recently. It wasn't a whole day; in fact, just a few hours of one day. 

Seeing appointments is a juggling act; not only because you see multiple different kinds of appointments in the same day, but also because you will often come across things in appointments that cannot wait to be treated. Wounds can be especially like this; not that they can't be stabilized and wait but if we are going to treat them and get them home in a timely fashion we will often work wound treatment into our day. This is a very perfectly balanced game of beat the clock. Depending on the wounds, I will sometimes tell people their pet absolutely has to spend the night. More often than not, it will be treated and return home that afternoon. On the particular day in question we saw a pet with a fairly extensive (but not terribly difficult to treat) wound on its side. It would be a straight forward task to explore the wound, remove and dead or infected tissue, flush the wound and then close it. And it went exactly like that: the pet's wound was extensive and had a large amount of infected tissue associated with it but everything was going great. We were able to clean the entire wound out, flush it and were getting ready to close the wound. We wouldn't even be running late for the next appointment. Then the pet died. Out of the blue. No changes noted on our monitoring equipment before hand, good strong heart beats and good deep regular breaths and then nothing. Silence. We fall back on our training in moments like this: commence resuscitation, get the client on the phone, explain the situation, continue resuscitation. In this case we were unable to bring the pet back. We lost. Anyone who has ever experienced this will tell you that if you were to offer them the choice of this situation and the feeling that comes with it or being sucker punched in the gut as hard as possible, they would ask you what the difference would be. The only real difference is you don't replay a sucker punch a thousand times wondering how you could have dealt with it differently. A sucker punch doesn't make you want to quit. A sucker punch just hurts for a little while.

I had to walk away from that situation and into an appointment that did end up having to wait for me because I was now running about forty-five minutes behind schedule. Of course the waiting client wasn't happy about waiting and while they might have understood if I had explained everything to them, they didn't need to have that heavy material laid on them at that moment. As it was, their pet wasn't feeling well and they wanted to be reassured that it was going to be alright. It was going to be fine but it was going to have to go see a specialist for its problem. While I was working that out over the phone, the owners of the first pet arrived. I spoke with them and answered as many questions as I could, and then went into my next appointment- a recheck appointment and suture removal for a wound treatment I had performed a little over a week previously. This pet had healed wonderfully and was doing very well. As I was talking to them at the check out desk about scheduling a grooming appointment for their pet now that the sutures were out, a very large dog with a very large wound came through the front door leaving a very large trail of blood behind it.

On a typical day, we deal with and experience a complete range of emotions. We knew what we were getting into before we stood in that hall and took the veterinary oath. That doesn't mean that some days don't absolutely devastate us. But we look forward to each and every day we get to go through these experiences with you and your pet. Thank you for giving us the opportunity.

 

My ideas about prevention.

The end of summer is the season of the itchy dog. We see several everyday at our clinic and while we treat each problem and each pet a little differently there is one that always evokes a similar response from me. The flea infested dog. Here are a few funny things about fleas. They are really small, you might not see them even if you're looking. They breed really fast, so by the time we do see a few adults there are probably thousands in your house. They make pupae just like caterpillars and those pupae are immune to every treatment short of burning down your house. This is why the following exchanges evoke a little bit of frustration in me.

A client brings in an itchy dog and I ask, "So you're keeping Cuddles on a flea preventative, right?" I am giving them the chance to absolutely make my day with this question. Unfortunately, I usually get one of the following responses, "I haven't seen any fleas," "We've never had a problem with fleas before," "We don't get fleas in our house," and my personal favorite, "I've looked, there aren't any fleas."

In my head there is this little sarcastic jerk who constantly needs to be silenced. I resist the urge to explain to people that if we wait until we see the problem we are trying to prevent to start prevention, we can't rightly call that prevention anymore. I would much rather prevent fleas on your pet than treat them. Just as I would much rather prevent fleas from being in my house than treat them.

Warning: there is a wild tangent coming up.

It does a person's pet no good to point those petty facts out to them and it turns out it doesn't make my day any better either. My job is to recognize that they have an itchy pet, this pet is uncomfortable, this pet owner feels badly for their pet and I have the knowledge and tools available to me to make this situation better. Not just that, but this owner took the time, effort and is going to pay the money to come and visit me out of all of the vets they could be seeing right now. How dare I make them feel silly for not completely understanding the life cycle of the flea! So I have started to try to teach people more about the why behind the how of veterinary medicine. Some people are interested, some people aren't. On a good day I can handle both types of people with ease, on a bad day... well, I'm a human being too.

How this leads me into holistic medicine is a bit of a stretch unless you know me well. I suppose the easy answer is that while I know there are all kinds of "natural" and "holistic" and "homeopathic" remedies for fleas, ticks and just about any other ailment you'll find, I don't recommend them because they either don't work or don't work as well as something else. People pay me to do what is best for their pet utilizing all of the available information we have. It bothers me to no end that someone who chooses to include within their "treatment" armamentarium a procedure, drug (all substances given with the intention to produce an effect are drugs regardless of what they are made of) or dietary change that has yet to be validated or has been invalidated by scientific methodology would be considered to be treating the whole animal more than I am.

My personal professional ethics dictate to me that treatments- whether preventative or palliative or curative- must have been exposed to criticism via the scientific method. I do this for two reasons. The first is obvious: if it survives the critical objective eye of good science it will work better for my patient than something that hasn't. The second reason is that if all of my plans, treatments and recommendations are based on scientific evidence then I will be less likely to resist changing them when something better comes along.

And it will. Because that is how science works, better ideas come along and we either adopt those ideas or we are left behind in our field. Look at what happened with the idea of "junk dna." We originally thought a huge percentage of dna served no purpose. Now we realize that it not only serves a purpose but is instrumental in carrying out multiple biochemical functions. Science accepted its idea was wrong, adopted the new paradigm and there will be a multitude of valuable therapies developed over the next few decades all stemming from that small change in thinking.

 

Two and a half months later.

I'm back! Sort of. With two young daughters, a new house and an ever growing practice I am finding i have less and less time for life's other pleasures. I will be posting more regularly than I have lately but more sporadically than I used to. I will not be sticking to a schedule as much either. The best way to catch blogs as I post them and to keep up with me in general is to follow me on facebook.

 

I am consistently amazed by the seemingly unnoticed complexities of our everyday encounters. The field of veterinary medicine, especially in community practice, is a hectic blend of encounters. We see you in appointments, have you drop off your pet for surgery, call you back with blood work results and sometimes even come to your home. Veterinary medicine, again-especially community practice, is a very high emotion world as well. Early on this wasn't as strong for me as it is now; the pets I was treating for serious diseases or even euthanizing were all still new to me and hadn't had a chance to imprint themselves on my psyche. It was a lot easier to maintain my emotional distance when I didn't know about the pet's trips to camp every summer or that the owner's son had just moved out west a few days before a bad diagnosis. As foreign as it was to me then, it is unavoidable now.

I am constantly trying to read the emotional tea leaves people wear on their faces and in their eyes and I shift conversations and lines of questioning to match what I am reading. That should have said what I think I am reading. I get it wrong sometimes but I am getting better. Really, the last vestige of emotional wilderness for me is the modern device known as the telephone. I just can't seem to read people well over the phone and it leads to amusing exchanges.

I received a phone call several months ago from a client who had let her dogs out on the back porch. The dog had been sprayed, directly in the face, by a skunk. This always happens at night and I have to encourage those vets who might be reading this to at least take client phone calls at night so that you don't miss out on these exchanges. To me a skunk spraying is not a medical emergency, to me it is a containment emergency. If one of my dogs were sprayed by a skunk I would be frantic to contain them before they touched anything I owned. That smell never leaves. But if you have never witnessed a dog having been sprayed by a skunk, it is most easily related to a recently pepper sprayed hippie. The results can be dramatic.

Needless to say that telling a client that her dog being sprayed by a skunk, even in the face, does not constitute a medical emergency would be inappropriate but I am constantly sidelined by the tangents telephone conversations take. Her concern wasn't that the dog was sprayed by a skunk or that it was hyper salivating. Her concern was that there were clearly some chemical substance that her dog had also been able to get into. On her porch. In the middle of the night. For those of you who have never had the pleasure of being directly present during a skunk spray, it smells like a tire fire in the middle of a chemical spill. They smell awful and not just rotten, organic garbage awful. It smells industrial. I have had no less than one dozen people tell me that their dog has been sprayed by a skunk and has also gotten into some horribly caustic chemical. The opinions on origin have ranged from industrial waste from the limestone slurry plant to old kerosene. I have had several of the same people call me the next morning to inform me that I do, in fact, know a little something about the subject and it was just a skunk.

Herein lies the crux of our tale tonight. This person clearly loves her dog a lot and is horribly concerned that it may have been exposed to something awful. Also the dog is in discomfort and if indeed it had been exposed to something caustic it is truly suffering at the moment. This is an emotional but (from my end of the phone) slightly humorous moment. I am tasked with, over the phone no less, dissecting her knowledge that her dog was sprayed by a skunk away from her fear that her dog is going to die from poison it most certainly did not encounter on her porch. Seems easy enough. But it has to be accomplished while still acknowledging her concern and not marginalizing her role in this. Of course this story has a happy ending and the dog does fine. But the complexity of the conversation that ensued to get the dog owner back from that ledge where she would have needlessly put her recently skunked dog in the car and rushed it to the hospital only to have me say, "Yep it's a skunk" pales in comparison to some of the more serious conversations we have while juggling phone calls, appointments and surgeries.

 

Clearing the way.

Root Canal Therapy.

More often than not a veterinarian is going to recommend extraction of a damaged or diseased tooth. There are several instances, however, where advanced dentistry is going to be not just a pleasant alternative but a better alternative. Some teeth are strategic for the integrity of the jaw, some are strategic in use, some are both. In very specific circumstances it is preferable to leave a strategic tooth in place whenever possible. Root canal therapy (often simply called a root canal) is one method of preserving a tooth that may have otherwise required extraction. This week I will outline the steps to a root canal therapy. It is worth noting that almost more than any other aspect of veterinary medicine, advanced dentistry, root canals, restorations, crown placement and orthodontics are extremely technique sensitive procedures. Without the proper training, practice and equipment a veterinarian can't just pick up and start to perform these procedures. Even with the right equipment, training and years of practice, failures occur; and fixing a failed procedure takes a lot more skill than doing it the first time. This is one of those procedures best performed by a veterinary specialist: they can be performed by a veterinarian who has extensive training in veterinary dentistry. They should not be performed by anyone else.

The first step in a root canal is to diagnose a tooth that would benefit from the procedure. This seems straight forward enough; and in most cases, it is. Any fractured tooth with exposure of the sensitive pulp tissue requires treatment. The two treatment options are root canal therapy or extraction. Sometimes teeth will suffer a traumatic insult that does not expose the pulp but does cause it to inflame. In these teeth the pulp chamber will look markedly different from the other teeth in mouth when we take oral x rays during a dental procedure. And finally, some teeth suffer bone loss at the apex of the tooth from a multitude of causes, including but not limited to bacterial infection of the pulp.

Even after a diagnosis is made there is one more step that has to take place before we can begin. That is selecting the appropriate patient for the procedure. A root canal is not a "set it and forget it" style procedure. They require monitoring and repair if they become damaged. They also require the right type of patient/owner. If your dog broke its canine tooth chewing on rocks and you recognize that you will be unable to prevent him from continuing to chew on rocks then a root canal is probably not going to be the best treatment for your dog. In any technique sensitive practice, the key to success is knowing and avoiding situations where you are likely to fail.

Once we have diagnosed an issue that is amenable to root canal therapy and have decided that the patient is a good candidate, we can start with the physical part of the root canal. The first step is accessing the canal. This is a bit different in every animal and it is where dental x rays become invaluable. The access is different for each tooth and is different for cats and dogs. For the remainder of this we will be talking about the canine tooth in the dog. Really the only difference between teeth is the access. You want straight lines for a proper root canal and in dogs the canine tooth is very curved. Making your access as close to the gum line as possible helps considerably in giving you a single straight access shot to the apex of the tooth. The initial hole is made with a small bur on a high speed drill. It is then filed wider and sometimes a slower running drill using a special bit is used to widen the canal. Each step in a root canal can only be as good as the step before it so if the access is no good the next steps won't be much good either.

Now that we have perfect access to the canal, we have to go in and remove as much of the pulp material as possible. To do that we insert a barbed broach, a long thin file with sharp spikes that grab the pulp material and then we gently pull the material out of the canal. This step is called extirpation and with a good access hole it only takes a few minutes. Since we are talking about a dog canine tooth I will mention that you do this step twice in this tooth because you will have two access points. One point is created at the tip of the tooth and one is close to the gum line.

Now that we have removed most of the organic material from the canal, we will irrigate a little with sodium hypochlorite and sometimes a little hydrogen peroxide. This is an important step and the one most likely to cause serious harm to the patient. Sodium hypochlorite is very toxic to tissue and if any escapes into the soft tissue structures around the tooth the pain can be unbearable. During this irrigation we are also shaping our canal with a series of files designed to remove small amounts of dentin from the sides of the canal. Some people use only hand held files, some use a drill mounted filing system and some use a mixture. I use only hand held files right now but will be upgrading after a few months of training. This is my favorite step, I like to find my working length and then irrigate, then add in a little of a root canal prepping lubricant, file a little, irrigate some more and repeat. Once you are certain you have a clean well shaped canal it is time to move on to the next step.

Drying the canal involves the placement of small paper points within the canal. These absorb all of the left over irrigation fluid and prepare the canal for a sealant. I typically rinse the canal at the end of irrigation with saline then I apply my paper point. Then I remove the point and rinse again with saline and use another paper point to dry the canal a final time. In multi-rooted teeth this process becomes slightly more complicated because the coronal or top part of the canal communicates with the roots and has a transverse portion.

The dry canal is now ready to be filled. I use gutta percha: a rubbery inert substance that comes in several forms. First, a sealant is applied to get to all of the very tiny areas the gutta percha will not reach. This is done using a bit called a lentulo on a low speed hand piece to reverse drill the sealant into place. A gutta percha point is then worked into place using tools called pluggers and spreaders to do just what their names imply. Once I feel the canal is properly filled I take an x ray to be sure everything looks acceptable enough to send to another veterinarian to be critiqued. If it doesn't look good enough to show off, then I look at what needs to be done to get it there. Sometimes that means starting over, usually it just means doing a little more spreading, plugging or adding in a bit more gutta percha.

Once everything looks acceptable it is time to cover our tracks. Here we not only get a chance to do some real artwork but we get to use some pretty cool toys as well. The big risk in the failure of a root canal is that bacteria are going to get in and ruin all of our hard work. To prevent this I cover my obturation with a layer of a glass ionomer. Then I use a light cured restorative to fill the access hole and "restore" the tooth. The restorative is light responsive so we hold an intensely bright blue light to the restoration for a minute or so. Mine looks like a ray gun and makes an awesome sound while it is running.

The finished product is then x rayed one last time and the patient is recovered from anesthesia. I like to see them back in one week, repeat the x rays in one month, six months and then every year after that.

Thursday mini post

This morning I had the privilege of attending an open meeting of Vermont's Veterinary Board. This group is composed of 4 veterinarians and 2 non-veterinarians. They are tasked with regulating our profession here in Vermont and also sometimes have to take disciplinary action when there have been complaints made against a vet. That's not why I was there today though!

The thing I would like to comment on today is how lucky you are, you the veterinary consumer here in Vermont. There are six people that meet every few months, sit down and discuss issues with the sole intention of protecting you the consumer. They approve our continuing education and this morning while they were discussing a particular course designed for veterinarians the following phrase was spoken in regards to a course that was being offered by a company trying to sell a product: "We're here to protect the veterinary consumer and if, as a consumer, I knew that was the sole place my veterinarian was receiving their CE I would be unhappy." And my heart soared! I though to myself, "Here is a group of people making an effort to ensure that pet owners are getting high quality veterinary care." It makes me proud to be a part of the profession.

The course ultimately received one quarter of the credit hours they were seeking and that was only after very deliberate discussion and consideration. I was very impressed.

Pet owners in Vermont can be pleased that they have an excellent veterinary board looking out for their best interests.

The veterinary board website is not terribly exciting but it does have all the information you would need if you want to attend an open meeting or look up your vet's license!

Vermont Veterinary Board