Setting Up a Dental Surgery

 Dental Equipment

Setting up a dental practice begins with purchasing the proper equipment and educating staff to diagnose and then perform the necessary procedure.  The practice staff must determine what level of dentistry they are capable of and interested in performing. This can be categorised as:

Stage 1 – Introduction of a homecare program. This would be available to puppies, kittens and all pet’s who have received dental treatment or advice. Covered in Homecare module.

Stage 2 – A basic but thorough supra-gingival examination and teeth cleaning, including scaling and polishing.

Stage 3 – A complete oral examination including radiographs and performing extractions and minor periodontal surgery.

Stage 4 – Stage 3 plus advanced procedures (or specialist procedures). These are covered individually in other modules.

The veterinary treatment of periodontal disease involves the mechanical removal of plaque and calculus.  I do not believe that you can scale the teeth adequately without the patient under general anaesthesia or using only electrical or air driven equipment.  Therefore, to complete the procedure properly, general anaesthesia and hand instruments must be used.

I use the following list as a guide to teeth cleaning, which I also use to explain the process to clients.

Dental Treatment Protocol

1.     Pre anaesthetic check and gross oral examination
2.     Pre anaesthetic pathology (blood work and urine analysis)
3.     Administration of antibiotics and/or anti-inflammatories/analgesics
4.     Administration of intravenous fluids
5.     General anaesthesia
6.     Operator protection (Mask, Gloves, Face Shield)
7.     Gross oral examination (record findings on dental chart)
8.     Periodontal Probing (record findings on dental chart)
9.     Gross removal of supra-gingival plaque and calculus
10.  Radiology
11.  Sub-gingival scaling (root planing and sub-gingival curettage)
12.  Polishing
13.  Sulcular Irrigation
14.  Extractions (if necessary)
15.  Guided tissue rejuvenation – local delivery antibiotics (Doxirobe/pluronic gel)
16.  Guided tissue regeneration (Synergy / membranes)
17.  Placement of barrier sealants (Oravet/SANOS)
18.  Discharge animal with home care instructions

Stage 2.

For a few $‘000s the clinic could be performing Stage 2 dentistry. The materials include erythrosine. The equipment in addition to a general anaesthesia machine, anaesthetic monitoring equipment and a table would include: a periodontal probe, hand held scaler, an ultrasonic scaler and slow speed polishing unit.  This may cover the majority of pets that are young without significant pathology.

Essentials for good technique

1.     Accessibility to the site
a.     Proper positioning of the animal

As your dentistry increases in frequency, the ergonomics of the procedure becomes very important. A bad habit performed once may cause a short-term problem, but when repeated all day, every day, it may result in a repetitive strain injury (RSI), permanent tendon, muscle or tissue damage. I place the patient in lateral recumbency. Good lighting and a comfortable chair are important, so that you can do the procedure with a straight back and extended arms.

The following are important factors you should consider when setting up your dental suite. You should be comfortable, have good visibility, improve magnification with loupes, use a chair and table which will provide the needed arm, hand and instrument rests and support and make sure you have a proper fulcrum for hand and instrument support when required.

A wet table and general anaesthetic set-up with a cat attached to the machine

A wet table and general anaesthetic set-up with a cat attached to the machine.

           b.     Appropriate mouth gag or prop

In order to perform successful dentistry without complications, you must be able to visualise what you are doing. A mouth gag, whether it be a European type that has a wire sprung bar placed caudal to the maxillary and mandibular teeth, or a spring loaded U shaped gag that contacts the tip of the canine teeth on opposite side of the jaw both will allow the caudal oral cavity to be visualized for dogs. If these are not available, a 3cc syringe can be cut off and engaged over the maxillary and mandibular canine teeth, being careful not to over-extend the TMJ.

Cats pose a completely different scenario, with respect to gags. I do not recommend any type of gag or artificial mouth opening device, as there are reports and a published paper on blindness in cats post dental surgery. This is thought to have been caused by pressure on the maxillary artery resulting to lack or cessation of blood to the brain and ultimate blindness. You’d be better to use your fingers and hand to keep the mouth open.

Gags to provide access into the oral cavity.

1.     Good visibility
 a.     Proper and precise lighting source

A general light or specific light source can be used. General light is achieved from an overhead light source. It must be moved manually and lights up the general area. Specific light is achieved from either a head mounted light, with or without loupes, or attached to the handpieces on your dental machine. A pair of optical loupes allows the veterinarian to magnify the area they are working on and therefore perform more precise and accurate treatment. A fibre optic light source is available on most high speed and ultrasonic scalers. It directs light to the area being worked on.

b.     Loupes

Magnification is paramount for dental procedures. Generally x2.5 – x3.5 is recommended. It is possible to obtain loupes that have a fixed focal distance so the ergomonical seating position is maintained and your back is protected. Loupes will make visualizing the work area better and your work will improve many times fold.

c.     Cheek and tongue retractors

Plastic cheek retractors are ideal for holding the lips and cheek out of the way. A tongue retractor, such as a Minnesota retractor, can be used to hold the tongue out of the operating field. This is especially important when a high-speed bur or scalpel blades are use

A Minnesota retractor 

d.     Good quality dental mirror

A mirror allows the operator to visualise difficult places without bending upside down and torturing your neck.

A dental mirror

Probing and Charting

Periodontal probes are used to measure the depth of the gingival sulcus and periodontal pockets.  They are typically a metal or plastic tapered rod with a blunt end attached to a handle graduated in millimetre markings. There are several types available.  The Williams, Marquis, Michigan-O and Nabors, are the most common types.  Selection is by personal preference.  The most common is the Williams, which is graduated in millimeters at 1, 2, 3, 5, 7, 8, 9 and 10 mm.  I like the Williams probe, as I find that the markings are easy to read.  The Marquis has alternating dark and light bands in 3mm segments at 3, 6, 9 and 12 mm.  On the Marquis probe, I have found the markings fade with continued autoclaving. The Michigan – O is graduated at 3, 5 and 8mm.

The ‘Williams’ periodontal probe

Disclosing supra-gingival plaque with erythrosine disclosing solution

Plaque can be disclosed using a dye.  One stage dyes stain all plaque the same color.  Two stage dyes stain new and old plaque different colours.  Fluorescein dyes require an ultraviolet light to visualize the plaque.  The greater the thickness of plaque on the tooth surface, the darker the dye.  The most common one stage dye is erythrosine.  Prior to cleaning the teeth, a drop of 2% erythrosine is placed on the supra-gingival tooth surface (included with the notes) and washed off with a gentle stream of water, from the triplex on your dental machine or via a 10cc syringe and 22 gauge needle.

Dental Charts

The cloud based, single click per pathology or treatment dental chart which I developed with an IT colleague, is available at www.vetdentalcharts.com. The chart does not require you to write on pads or paper, can’t be lost, does not need to be scanned and easily can be saved to the client management record or printed for the client as a permanent take home. The added information allows you to inform the client of your treatments and educate them on homecare, ensuring they follow your recommendations for a successful outcome. The charts will allow you to confidently record pathology and treatment in dogs and cats, print homecare instructions, record local nerve blocks, clinical photographs and mount radiographs using the AVDC approved mounting protocol.

Canine dental chart

Supra-gingival Scaling

Gross plaque and calculus deposits can be removed from the supra-gingival surfaces of the teeth with tartar removing forceps, hand-held scalers or power scalers.  Removal of supra-gingival plaque and calculus is termed ‘scaling’.  Tartar removing forceps are designed in a similar fashion to extraction forceps, with the difference being they have one curved beak and one straight beak rather than two straight beaks.

Calculus removing forceps

Hand scalers

Hand scalers have a handle connected to a blade, which has a double-sided cutting edge that converges to a sharp point.  The blade is triangular in cross section.  The sharp blade is used to remove plaque, calculus and other deposits from the supra-gingival tooth surface.  They are held in a modified pen type grasp.

Hand scalers are also termed sickle scalers, based on their design and appearance.  The most common are the Universal (or H6/H7), the Jacquette and the Morse.  The Universal is the most common in Veterinary practices.  The Universal has a long blade, the Jacquette has a medium sized blade and the Morse have small, almost miniature size blades. Some veterinary practices, hoes and files are commonly used.  Hoes are flat blades bent at 99 degrees to the handle.

A curved scaler (A Universal – H 6:7

A curved scaler (A Universal – H 6/7.

A short blade scaler (Morse)

A short blade scaler (Morse).

Dental units

A basic dental unit contains an air source to run the handpieces, which include a high speed line, a slow speed line, an ultrasonic scaler and an air/water syringe. The high speed line takes a drill which runs bur operating at 400,000 rpm. It should have water cooling and is used to section teeth into individual segments for easier extraction; removal of bone for easier extraction; and removal of tooth for crown preparation. The slow speed line takes a drill or polishing handpiece which is used with paste and a polishing cup after the teeth are clean to smooth the surface. An ultrasonic handpiece is used to remove calculus and plaque and the air/water syringe can be used to wash off plaque and debris after cleaning. as well as blood. One of best machines on the market is the Ultima range, U250 and U500. The U500 contains all of the above and an air compressor to run the unit, all contained in an easy to clean, nicely presented fibreglass casing to keep dog and cat hair away from the parts and tubes. This is a nice mobile unit. The U250 is a table top machine that is small and has the above handpieces but no air source, which requires either an air cylinder or a separate compressor.

 

Ultrasonic scalers

Ultra-sonic scalers may be used for removal of supra-gingival plaque and calculus.  Ultrasonic scalers operate at >25kHz.  The principle action of plaque and calculus removal is either by a mechanical action or cavitation.  The mechanical action is achieved by the vibrating tip contacting the calculus and breaking it off.  Cavitation is the production of sound waves derived from physical vibrations of the tip energizing the water spray, which then clean the tooth.  The cavitation effect can be dangerous to the operator. Cavitation produces a bacteria laden aerosol that when inspired by the operator may result in a respiratory infection.

Ultrasonic scalers run via electricity and the working tip has one of three types of movement.  The magneto-strictive type utilize a stack of parallel nickel strips that lengthen and shorten when subjected to alternating electrical current.  This causes the tip of the scaler to move in an elliptical figure of 8 motion.  There are two classes of stacks, one vibrates at 25kHz, the other at 30 kHz.   The piezo electric type scaler utilize a crystal in the handle that expands and contracts when subject to alternating current.  This causes the scaler tip to move in a linear back and forth motion.  It vibrates at 25 to 45 kHz.  The ferric rod type scalers use a rod, which vibrates by expansion and contraction.  This causes the titanium scaler tip moves in a circular or elliptical fashion.  The ferric rods vibrate at 42 kHz.

Acteon Satelec P5 ultrasonic scaler

Polishing

Polishing the tooth surface following scaling is performed to remove any microscopic plaque and calculus and to provide a smooth tooth surface that retards the re-attachment of plaque and calculus.  The polishing cup is a silicon or rubber cup placed on a slow speed handpiece. Pastes are available in different flavours and grades. Bubblegum, Mint, Pina Colada and Banana are popular.  Fine grades produce a smoother finish, whereas course grades will remove more enamel and produce a rougher surface.  It is also possible to purchase paste in a multi-use jar or individual caplets.

Prophy paste in a single uni-dose cup

Prophy paste in a single uni-dose cup.

A polishing cup on a slow speed motor for polishing

A polishing cup on a slow speed motor for polishing.

SANOS

SANOS is a liquid polyvinyl that is applied by a small brush directly to the gingival sulcus and margin post scaling and polishing. The sealant seals the gingival sulcus against penetration of plaque but still allows the transversing of sulcular fluid and oxygen. The sealant has VOHC approval for reduction in plaque and calculus accumulation.

Sanos

Stage 3.

The business must purchase hand held curettes for periodontal therapy, local delivery antibiotic medications, extraction equipment, high speed dental drills and radiograph machines and film or sensors.

Radiology

Radiology is a vital tool in veterinary dentistry that can be used to assist in the diagnosis, treatment planning and monitoring of oral disease.  It can be utilized to confirm missing teeth; diagnose diseases, such as periodontal and endodontic conditions; and confirm treatment procedures, such as complete tooth extraction.

An ACTEON XMIND wall mounted xray generator

The Acteon DR #2 sensor

The ACTEON Sopix2 xray sensor

Sub-gingival Scaling (Root Planing) and curettage

Complete treatment of established periodontal disease requires sub-gingival scaling and curettage.  The term root planing is used to describe scaling of the tooth root.  The act of root planing removes plaque, calculus and other foreign matter, i.e. hair, food, from the periodontal pocket, as well as, the superficial layer of endotoxin rich cementum from the root surfaces.  The term gingival curettage is used to describe the action of scraping the necrotic epithelial cells, endotoxins and accumulations from the epithelial wall lining the pocket.

Root planing and sub-gingival curettage can be performed using two types of curettes, the Universal and the area-specific.  The Universal type, which Columbia and Barnhart are examples, have two cutting surfaces, a rounded toe and a blade with cutting surfaces angled at 90 degrees to the handle.  The area-specific type, which Gracey is an example, has a rounded toe and a single sided cutting blade, which is angled at 70 degrees to the shaft (which is the part of the instrument between the cutting blade and the handle).  I believe that Gracey curettes are the best for sub-gingival scaling and curettage as they adapt to the anatomy of our patients’ tooth roots.

The Barnhart 1:2 curette

The Barnhart 1/2 curette

The Gracey 7:8 curette

The Gracey 7/8 curette.

The Columbia 13:14 curette

The Columbia 13/14 curette.

The mini Gracey 1:2 curette

The mini Gracey 1/2 curette.

Local delivery system antibiotic

Doxycycline or clindamycin impregnated polylactic acid polymer gel.  Following root planning, gel is placed into the periodontal pocket.

Diagramatic demonstration of gel usage

Diagramatic demonstration of gel usage.

Synergy osteoconductive synthetic bone material

Synergy is an osteoconductive synthetic material, which can be used in periodontal pockets to promote new alveolar bone production and encourage re-attachment of the gingival tissues and periodontal ligament or into post-extraction sites to maintain bone density.

Synergy crystals are a mixture of tricalcium phosphate and hydroxyapatite

Synergy crystals are a mixture of tricalcium phosphate and hydroxyapatite.

Local analgesia injection (pre-emptive analgesia) by regional nerve block

Used in combination with general anaesthesia should be performed to decrease peri-operative pain, as well as, increase post-operative comfort and healing. Purchase of local anaesthetic, syringe and needles.

Aspirating syringe, anaesthetic carpules and dental needles

Aspirating syringe, anaesthetic carpules and dental needles.

Extraction equipment

The types of instruments that I find useful and necessary for a successful extraction include:

a.     Scalpel blade – #11 or #15
b.     Periosteal elevator
c.     High speed handpiece
d.     Round bur – #2 and #4
e.     Tapered fissure bur – #699 and #701
f.      Dental instruments – elevators: straight /winged / curved deciduous / root tip pick

High Speed handpiece

High Speed handpiece

Elevators

1.     Straight

The traditional elevator is termed ‘straight’. It consists of a handle, shaft and working end. The working end consists of a blade with parallel sides, a concave and opposing convex surface with a rounded tip. The tip may be sharp or blunt.

A straight elevator

2.     Winged #1 – #8

Winged elevators are a variation of the straight elevator. The working end has a concave surface and opposing convex surface, flared sides, with an appearance of a wing, and a rounded tip, which is sharp. The winged elevators were designed by Dr Bob Wiggs, of Dallas Dental Clinic for Animals, Dallas, Texas and are available from a number of companies. The working tip is available in a variety of sizes from 1mm to 8mm, and they are designated #1, #2, etc to #8.

A winged elevator

 

A winged elevator.

3.     Feline specific elevators

The EX-5XS perfect for feline teeth

The EX-5XS perfect for feline teeth.

The 1.3S-XS super slim elevator designed for feline tooth roots

The 1.3S-XS super slim elevator designed for feline tooth roots.

4.     Coupland chisel and luxators

The luxator consists of a handle, shaft and a working end. The working end has a concave surface and opposing convex surface, straight sides and a sharp end perpendicular to the instrument long axis.

5.     Root tip pick

The root tip pick has a sharp pointed tip that is used to loosen the apical tip of a root if the root inadvertently fractures during elevation.

A root tip pick

A root tip pick.

6.     Curved deciduous elevator

The curved deciduous elevator consists of a handle with two working ends at opposite ends of the handle. The first end is angled to have a concave surface and is used against the convex tooth root surface, whilst the other end has a convex surface to be used against the concave tooth root surface. It is used on the cranial and caudal surface of a curved deciduous tooth root.

A curved deciduous elevator

A curved deciduous elevator.

Extraction forceps

Extraction forceps have two handles and two beaks, which are opposed when the handles are squeezed together. The beaks are used to grasp the tooth crown in order to extract it from the alveolus.

A pair of extraction forceps

A pair of extraction forceps.