Dental care. Dental care 2/3/2015

Transcription

1 , anesthesia, weight management and fitness, behavior Mark D. Freeman, DVM, DABVP, CVA Assistant Professor, Community Practice VA-MD College of Veterinary Medicine Dental diseases May include dental fractures, enamel defect, tooth resorptive lesions, gingivitis/stomatitis, periodontal disease, neoplasia, and trauma MUST remember: many dental diseases are painful, but animals show few, if any, signs of pain, inappetence, or loss of chewing behavior After dental disease is treated and resolved, owners frequently comment that their pet is like a puppy/kitten again % of canine and feline patients presented to your practice will have periodontal disease, making this one of the most common diseases in small animal practice! Likelihood of periodontal disease increases with age Patients are almost never too old for anesthesia if it is done properly help your clients get past that thought Gingivitis Initial process of swollen and/or inflamed gingival margins +/- hemorrhage Most often caused by bacterial plaque in conjunction with host responses Bacterial endotoxins proliferate, can lead to tissue destruction 1

2 Periodontitis Secondary hard and soft tissue destruction (progressive periodontitis) Leads eventually to loss of periodontal support over time (usually years) Periodontitis An association has been established between periodontitis and cardiovascular-related events, and microscopic hepatic, renal, and CNS lesions in some veterinary patients In humans, there is a correlation between presence and severity of periodontal disease, and circulating inflammatory markers Treatment Complete dental cleaning and treatment Dental prophylaxis is a misnomer majority of pets already have dental disease Dental cleaning and treatment must be performed under anesthesia to adequately address subgingival pathology, radiographic imaging, and periodontal treatment as needed Sedation dentistry or awake dentistry is essentially malpractice! Steps for a thorough dental cleaning Preliminary exam and evaluation with client communication Supported general anesthesia with protected airway Oral exam and planning under anesthesia Gross calculus removal SUBGINGIVAL CALCULUS REMOVAL Periodontal probing 2

3 Steps for a thorough dental cleaning (con t) Exam for missed plaque and calculus (apply disclosing solution or air dry) Periodontal diagnostics and treatment as needed Polishing Sulcus irrigation Final charting Client education and home care Home care Ideally daily; minimally twice weekly Brushing veterinary enzymatic toothpastes Oral rinses chlorhexidien, CET, Zn ascorbate Water additives HealthyMouth received the VOHC seal of acceptance; claims to decrease plaque by 72 and 77% Dental diets mechanical removal of plaque/tartar, hexametaphosphate (see for listing of diets) Tooth Resorption Nomenclature has changed from Feline Odontoclastic Resportive Lesions (FORL) to simply tooth resorption Second only to periodontal disease in the cat Idiopathic activation of odontoclasts results in destruction and resorption of the tooth, often in its entirety AVDS reports that 60% of cats over 6 years of age have at least one, if not multiple, resorptive lesions Tooth resorption Lesions seen at or below the cemento-enamel junction, usually on the buccal aspect of the mesial and distal edges, or Lesions may develop further apically around the root (most commonly involving canine teeth) Premolar and molar teeth are most commonly involved although any tooth can be affected Tooth resorption Tooth resorption occurs in dogs also 3

4 Most anesthetic complications are associated with insufficient monitoring and reversal of declining trends: e.g. hypotension, hypothermia, hypoxia, bradycardia A 1993 study showed a mortality rate of 0.1% associated with anesthesia, primarily associated with xylazine and declining cardiac trends Adequate monitoring is essential Prior to the procedure Good client communication advise the owner of potential risks and complications, but also that good protocol will be followed Pre-anesthetic screening is very important CBC Serum chemistry Urinalysis ECG Many options for sedation and anesthetic drugs which can be used in combination to provide safest option for the patient Premedication/sedation are highly recommended Reduces stress/anxiety in the older patient Decreased the dosage of induction and maintenance agents Offers preemptive pain control when appropriate analgesics are used Local blocks can be very useful Premedication combinations Acepromazine at 0.01 to 0.04 mg/kg with hydromorphone at to 0.1 mg/kg Dexmedetomidine at to mg/kg with hydromorphone at to 0.1 mg/kg Dexmedetomidine at to mg/kg with butorphanol at 0.1 to 0.4 mg/kg All can be given IM or IV Dexmedetomidine can be reversed when needed 4

5 Induction agents Propofol is a safe and effective induction agent due to its short duration of action Typically administered at 6 mg/kg to effect, giving ~1/3 of the dose as a bolus, then titrating Some patients only require ¼ the dose to achieve total effect, and some require the entire dose monitoring is important Induction agents Alfaxolone injectable anesthetic is on the horizon for approval in the US Similar in effect to propofol, but shorter recovery times Close monitoring during recovery is recommended IV administration Safe to be used alone or with other premedications/sedatives Venous access is essential IV fluids to maintain blood pressure Current AAHA recommendation is 5 ml/kg/hr for dogs and 3ml/kg/hr for cats Fluid boluses rarely have a positive effect on blood pressure may try once or twice Administration of a bolus of Hetastarch (6%) may be effective at elevating blood pressure 1-2 ml/kg/hr not to exceed 20 ml/kg per day in dogs or 10 ml/kg/day in cats Dopamine CRI at μg/kg/min is typically very effective at elevating blood pressure A syringe pump works well for administration Glycopyrrolate is much more effective than atropine at correcting bradycardia 0.1 mg/kg IV, give ½ dose initially and if inadequate response within 2-3 minutes, give second ½ Monitoring is vital to successful geriatric anesthetic procedures during the procedure, and during the recovery A study of anesthesia associated deaths in the UK looked at nearly 170,000 anesthetic cases and found that nearly 50% of anesthesia associated deaths occurred within 3 hours of ending anesthesia 5

6 Be proactive and start early teaching clients to recognize ideal body condition, and to feed to achieve a body condition, rather than a set weight Give owner guidance on approximate caloric requirements and amounts of food to be fed daily: Calculate RER (kcal/day) 70(BW kg ) 0.75 or 30(BW kg ) + 70 Calculate daily energy requirement (DER) = RER X DER factor DER factor for growth is 0.8 to 1.8 for adult maintenance From Small Animal Clinic Nutrition VM 8264 notes, Dr. Iveta Becvarova Caloric requirements Energy needs decrease in middle age Studies have shown an ~18-25% decrease in maintenance caloric requirements in older dogs, with greatest decline at >7 yrs of age For cats, a decline of ~3% per year in maintenance caloric requirements was seen through 12 yrs of age Maintenance caloric needs actually increased in cats >12 yrs of age 6

7 Pet owners cite behavior problems as one of the primary factors leading to relinquishing or euthanizing a pet One study showed these as the primary complaints when dogs 9 years or older were surrendered to a shelter: Separation anxiety 29% Aggression toward people 27% House soiling 23% Excessive vocalizing 21% Phobias 19% Waking at night 8% Compulsive/repetitive behaviors 5% Intra-species aggression 5% In cats, house soiling accounts for 73% of cases seen in three behavioral referral practices The next most common reasons for referral to a behaviorist: Intra-species aggression 10% Aggression toward humans 6% Restlessness 6% Overgrooming 4% Another study in dogs over 7 years of age included cognitive dysfunction in 7% of the subjects In a recent survey conducted by Hill s Pet Nutrition, one or more signs of CD were recognized by owners in 75% of dogs 7 years of age or older In another study, 35% of cats 11 years of age or older had signs consistent with CD 7

8 Signs of CD include disorientation, altered sleep-wake cycles, decreased responsiveness to stimuli, decreased interactions with owner, decreased activity levels, and increased house soiling Looking for causes of behavioral changes Rule out medical reasons such as osteoarthritis, urinary tract infection, hyperthyroidism, vision loss, hearing loss the list goes on Identify primary behavioral problems OCD Treat and manage the signs of behavioral dysfunction Nutritional and dietary therapy Supplementing senior diets with antioxidants Environmental enrichment In limited studies, the combination of dietary enrichment and environmental enrichment produces the greatest improvement in cognitive function Drug therapy Selegiline (Anipryl TM, Pfizer) us a monoamine oxidase B inhibitor which produces clinical improvement in CD Antidepressants and anxiolytic may be useful for accompanying signs Best utilized through a joint effort with a behaiorists Visit the American Veterinary Society of Animal at for position statements on a variety of topics such as dominance, punishment, puppy socialization, and choosing a trainer The American Association of Feline Practitioners publishes an excellent guide to feline behavior which may be downloaded at or_guidelines.pdf 8

9 Questions? 9