Clinic Protocol for Dental Disease

STEP 1: Comprehensive Overview CLINICAL SUITE: DENTISTRY Clinic Protocol for Dental Disease Jan Bellows, DVM, FAVD, DAVDC, DABVP All Pets Dental Weston, Florida Each member of the team needs to appreciate the importance of committing to dental care.! BOTTOM LINE Treat each tooth as a separate patient: some will be in great shape, others not so great. LOOK FOR 3 Halitosis 3 Gingivitis 3 Periodontal disease 3 Oral growths 3 Fractured teeth 3 Tooth resorption 3 Retained deciduous teeth DIAGNOSTICS 3 Flip the lip 3 Dental radiographs 3 OraStrip diagnostic test (orastrip.com) 3 Periodontal probing under anesthesia 3 Mobility testing TREATMENT 3 Local antimicrobial application 3 Periodontal surgery 3 Oral surgery 3 Extraction REFER WHEN 3 Cases require special anesthesia and monitoring 3 Specialized equipment is required 3 Specialized skills (oral surgery, endodontics, periodontal flap procedures to save teeth, crowns, orthodontics) are needed FOLLOW-UP 3 3 days 3 7 days 3 1 month RECEPTIONIST VETERINARIAN PRACTICE MANAGER Be a source of dental information Inform the client of expenses for examination, anesthesia, cleaning, radiographs, and possible additional fees after each tooth is examined Know the prevention products Always examine tooth by tooth Sharpen dental extraction instruments before each surgery Prepare sterilized dental packs for each procedure Learn cleaning and radiology skills Give home care instructions Appreciate the good you can do through dentistry Take full-mouth radiographs as part of each patient's examination Address or refer any abnormalities Obtain training if needed Create a dental practice within your practice Supply the doctors and technicians with the best equipment and education Stock dental products recognized by the Veterinary Oral Health Council (VOHC; VOHC.org) Step 2: Team Education Primer 8 veterinaryteambrief.com Veterinary Team Brief January/February 2013

STEP 2: Team Education Primer CLINICAL SUITE: DENTISTRY Canine Dental Disease Jan Bellows, DVM, FAVD, DAVDC, DABVP All Pets Dental Weston, Florida DISEASE TYPES Periodontal diseases (infection between teeth and gums) Gingivitis (inflammation of the gums) Halitosis (bad breath) Gingival hyperplasia (gum growth covering part or all of the tooth) Oral tumors Tongue lesions CAUSES General Daily plaque accumulation Tartar (calculus) forms from plaque Rough tartar accumulates more plaque Bacteria growth between the teeth or from infected gums Orthodontic Disease Causes Inherited Failure of deciduous (baby) teeth to resorb, allowing adult tooth eruption HISTORY & CLIENT COMPLAINTS Bad breath Poor appetite Dropping food when eating EXAMINATION & SIGNS Halitosis Inflamed gums Bleeding gums Mobile teeth TREATMENT In-Clinic Dental scaling and polishing under anesthesia Gum surgery and/or tooth extraction Medical management and/or locally applied antimicrobials At-Home Options Twice daily tooth brushing Twice daily use of dental wipes Feeding VOHC-accepted diet PREVENTION Dental diets Treats Water additives Gels Toothpastes Twice daily home care VOHC-accepted plaque and calculus control products (VOHC.org) What s It Mean? FLIP THE LIP Lift the dog s lip up entirely in order to see gum line. Quick Points Raise the lips to expose the underlying teeth and gums. Look at both sides. Place your thumb inside the upper jaw to open the mouth. Note any abnormalities in the medical record.! BOTTOM LINE Twice daily attention to plaque control Semiannual examinations Professional cleaning when plaque/calculus has accumulated on the cheek teeth Step 3: Communication Script 9

STEP 3: Communication Script What to Say Jan Bellows, DVM, FAVD, DAVDC, DABVP All Pets Dental Weston, Florida Need to Know Bad breath is never normal. A thorough tooth-bytooth examination is necessary in every case. Prevention of plaque and tartar are as important as any other part of the visit. When the client, Mrs. Jones, came in 2 weeks ago with her dog, Rusty, for a wellness appointment, she expressed her concerns about Rusty's bad breath. Dr. Miller examined Rusty's teeth and talked about the importance of home care and the need for Rusty to have a dental cleaning. Dr. Miller provided Mrs. Jones with some educational material on canine oral care and recommended that she return in 2 weeks when they would have more time to review the procedure and Rusty's specific needs. This is the follow-up visit. GREET Owners need to feel comfortable and prepared to meet the technician and the veterinarian. Receptionist: Hi Mrs. Jones. It s so good to see you and Rusty again! Sarah, our technician, and Dr. Miller will be with you shortly. INFORM Owners need to understand the importance of dental care on systemic functions. Technician: Hi Mrs. Jones. We are so glad that you could come in today to discuss Rusty s bad breath. Just like you and me, Rusty s bad breath could be caused by dental disease, so today we will be performing more than just a routine examination. What questions do you have before we get started? EXAMINE & CONFIRM Owners need to understand what the veterinarian is looking for when making his or her diagnosis and treatment plan. Good morning, Mrs. Jones! Did our technician, Sarah, go over everything we need to address today? Feel free to ask me anything while I take a look at Rusty and see if we can resolve his bad breath. EXPLAIN Ensure you understand the client's perspective, concerns, and preferences for depth of explanation. This allows the explanation to be geared to the right level and right topics. Owners who are part of the decision-making process are more likely to follow through with your recommendations. Based on your concerns about Rusty's bad breath and his dental stage, I recommend that we perform a professional cleaning, evaluation, and treatment under anesthesia. To do this right, Rusty will need to be asleep for the procedure. Dogs don't tend to be very good about keeping their mouths open for us when we clean under the gums! Before we continue, do you have any questions? Receptionist: It was so good to see you and Rusty, Mrs. Jones! Dr. Miller would like to see Rusty again in 2 weeks for his dental cleaning. Is Wednesday or Thursday a better day for you? 10

CLINICAL SUITE: DENTISTRY Owners need to feel comfortable and prepared to meet the technician and the veterinarian. DAY OF THE PROFESSIONAL TEETH CLEANING Owners need to feel comfortable and prepared to meet the technician and the veterinarian. Receptionist: Hi Mrs. Jones. It s so good to see you and Rusty again! Sarah, our technician, and Dr. Miller will be with you shortly. INFORM Owners need to understand the professional oral assessment, treatment, value, and prevention visit process. Technician: Hi Mrs. Jones. We are so glad that you could come back to care for Rusty's bad breath. Today we plan to anesthetize Rusty in order to perform a tooth-by-tooth examination to find out the cause of his bad breath, perform needed treatment, and tailor prevention to keep it under control. Do you have any questions before we get started? Good morning, Mrs. Jones! What questions can I answer before we get started on Rusty's dental procedure? We'll be doing the procedure around noon and will need to discuss our findings and any additional fees before we continue with necessary treatments. Can you leave us a number to call between noon and 2 PM? CALL THE OWNER Mrs. Jones, Rusty is doing really well under anesthesia. We found that he has 3 teeth that are diseased. One is loose in the socket and the other 2 have advanced periodontal disease. The loose tooth needs to be extracted and the diseased teeth need to be treated with locally injected antibiotics. DEMONSTRATE When the owner picks up the pet, explain each step as you brush the pet's teeth. Owners who understand the procedure are more likely to comply. Technician: Do you think that you will be able to do this on a daily basis? FOLLOW UP Owners need to feel satisfied with the visit and empowered to be involved with their pet's preventive care. You can practice good dental care at home by brushing Rusty's teeth, giving dental chews, and using water additives. This will be important for his long-term health. COMPLIANCE CONNECTION Remember that a routine subject for you may not be routine for your client. Research has indicated that people must hear new information at least 7 times to fully comprehend it. Determine and understand the client's perspective and starting point (has he or she had a previous experience with dental disease? Is there an understanding of dental home care?). Provide the client with additional sources of information (eg, handouts, websites). Steps 4 & 5: Team Workflow & Roles 11

STEP 4: Team Workflow Dental Procedure Jessica Goodman Lee, CVPM Brakke Consulting Dallas, Texas Greet the client and pet Note specific client concerns regarding the pet s mouth Call the technician to the front to bring the client and the pet to the examination room! RECEPTIONIST BOTTOM LINE Be sure to get informed consent and a contact number where the client can be reached during and after the procedure. Lift the lip and briefly examine teeth to make sure that the treatment plan reflects the extent of dental disease Review the treatment plan with the client; ensure that if extractions are anticipated, these are indicated on the high end of the cost estimate Ask the client about his or her specific concerns Have the client sign the treatment plan and anesthesia release form Provide the client with a copy of the treatment plan Perform the dental cleaning and take radiographs based on the veterinarian's instructions Take before-and-after photographs of the pet's mouth STEP 5: Team Roles 1 RECEPTIONIST 2 First and final point of contact with client Schedule appointments Discuss the oral assessment, prevention, and treatment visit with the client Discuss fee questions Record contact information (including email) Follow up with clients Reiterate the importance of preventive dental care Be familiar with all home-care products in order to make and/or reemphasize recommendations Client educator Ask about the client's starting point Work with the veterinarian to document oral examination Know how to assess a patient's dental grade score Be familiar with all dental home-care products Provide a hands-on demonstration of teeth brushing and other home-care options Reiterate the importance of preventive dental care 12

CLINICAL SUITE: DENTISTRY RECEPTIONIST Greet the client and have him or her pay for the procedure (another option is to request payment after reviewing details with the technician) VETERINARIAN Make sure to contact the client during the procedure if radiographs or diagnostics show issues not previously noted on the treatment plan Call the client after the procedure to update on findings and any medications to be given at home Complete a dental report card for the client to take home and include before-and-after photographs Commend the client for making a good decision and let him or her know how much better the pet will feel Review the report card and photographs Answer the client's questions Explain to the client that he or she needs to schedule a recheck examination in 1 to 2 weeks, when a home-care regimen will be determined RECEPTIONIST Accept payment for the procedure Schedule a recheck appointment for 1 to 2 weeks Provide the client with a reminder card and call him or her the day prior to the appointment Bring the pet to the client to take home Clarify the instructions and check for client understanding/comprehension 3 VETERINARIAN 4 PRACTICE MANAGER Medical expert Examine the patient before and during anesthesia Diagnose the condition Provide a treatment/management plan Emphasize the importance of preventive dental care Business supervision/management Set quantifiable goals for dentistry education and procedures/sale of dental products Provide training/meetings Implement a dental preventive care marketing campaign Facilitate dental care for employees' pets Review medical records to ensure each pet's oral health condition is being recorded and dentistry recommendations are being made Step 6: Team Training Plan 13

STEP 6: Team Training Plan CLINICAL SUITE: DENTISTRY Training the Team Jessica Goodman Lee, CVPM Brakke Consulting Dallas, Texas TIP Similar role playing should be done by each staff member, based on his or her role and interaction with the client. Staff members should be encouraged to employ different scenarios and answers. The road to success is paved with practice. Following is a detailed meeting agenda and role-playing guide for meeting facilitators to help their teams embrace and adopt a successful dentistry protocol plan. AGENDA 3 Designate a team leader for improving dental disease protocols 3 Meet as a group to identify target dates and objectives: Incorporate dental examinations and dental care into preventive medicine protocols Treat/manage dental disease Prevent recurrence of dental disease Educate clients Increase client compliance Generate revenue 3 Educate team members on the value of dental care in patient wellness 3 Communicate the roles and responsibilities of each team member 3 Develop a strategy to encourage client compliance and participation WHEN INTERACTING WITH CLIENTS Prepare yourself mentally Clarify your role and negotiate an agenda Understand the client's concerns, ideas, perceptions, and constraints Use open-ended questions Be mindful of nonverbal behaviors (smiling, nodding, eye contact, facial expressions, sitting down) Demonstrate active listening ( I see, Go on, Tell me more about ) Ask the client to repeat back the information to ensure understanding and allow the veterinarian or technician to clarify areas of confusion ROLE PLAY! Encourage the receptionist to play the role of the pet owner with the technician. Ask the employee to volunteer his or her dog for the demonstration. Technician: I understand that Rusty has bad breath. Can you tell me more about your concerns? Pet Owner: His breath has become worse in the past 2 months or so. I'm not sure what to do about it. Technician: I see. Can you tell me what type of food Rusty eats? Does he get any specific type of treats? Pet Owner: We give Rusty grocery store dog chow every morning and night, and we give him soft meat chews for treats. Technician: Do you currently brush Rusty's teeth at home or use any other dental care products? Pet Owner: No. I tried to brush his teeth once, but he did not like it at all! Technician: I understand. Let's take a quick look at Rusty's teeth [lift lip]. Dr. Miller will conduct a full examination so we can determine what is going on. Do you have any other concerns you'd like to discuss before we proceed? Step 7: Client Handouts 14