Diabetes in Pets
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Many pets, especially older pets, have gingivitis<ref> [http://www.nlm.nih.gov/medlineplus/ency/article/001056.htm Gingivitis]</ref> (inflamation of the gums) or periodontis<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/001059.htm Periodontis]</ref> (recession of supporting bone and gingival attachment) and have to undergo a dental procedure to clean plaque and calculus from their teeth and to extract diseased teeth. Although dental procedures are increasingly common on nondiabetic animals, the procedure is especially important to minimize underlying low grade infections in diabetic animals. That infection may be hindering [[regulation]]. Some caregivers report lower blood glucose readings after an animal finishes its post-procedure antibiotics.
  
Many pets, especially older pets, have gingivitis<ref> [http://www.nlm.nih.gov/medlineplus/ency/article/001056.htm Gingivitis]</ref> (inflamation of the gums) or periodontis<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/001059.htm Periodontis]</ref> (recession of supporting bone and gingival attachment) and have to undergo a dental procedure to clean plaque and calculus from their teeth and to extract diseased teeth. Although dental procedures are increasingly common on nondiabetic animals, the procedure is especially important to minimize underlying low grade infections in diabetic animals. That infection may be hindering [[regulation]]. Some caregivers report lower blood glucose readings after an animal finishes its post-procedure antibiotics.
   
−
Because of the extra risks, some veterinarians prefer not to perform a dental procedure on a diabetic animal with high or erratic blood glucose levels unless it is considered an urgent situation. This can create a Catch-22<ref>[http://en.wikipedia.org/wiki/Catch_22 Wikipedia: Catch-22]</ref> situation because your pet may have very high or erratic blood glucose levels because of dental infection. This is a [[:Category:Vicious circles|vicious circle]] situation that you should discuss with your veterinarian. You also may want to consider consulting a veterinary dental specialist.
+
Because of the extra risks, some veterinarians prefer not to perform a dental procedure on a diabetic animal with high or erratic blood glucose levels unless it is considered an urgent situation. This can create a Catch-22<ref>[http://en.wikipedia.org/wiki/Catch_22 Wikipedia: Catch-22]</ref> situation because your pet may have very high or erratic blood glucose levels because of dental infection. If you feel this is the case with your animal, you should discuss this with your veterinarian. You also may want to consider consulting a veterinary [http://www.cosmetic-dentist-implant.com/dentist-in-weymouth.php dental specialist] .
   
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A dental procedure requires general anesthesia. General anesthesia poses a risk for any animal, and is a special concern for older or “special needs” animals. Therefore, the caregiver should have a basic understanding of appropriate dental procedures to be able to ask about them beforehand.
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A dental procedure requires general anesthesia. General anesthesia poses a risk for any animal (or human), and is a special concern for older or “special needs” animals. Therefore, the caregiver should have a basic understanding of appropriate dental procedures to be able to ask about them beforehand.
   
−
A dental normally is an out-patient procedure and, barring complications, your pet should come home the same day. The cost of the procedure can vary widely depending on the clinic and the number of extractions, but you can expect to pay between $250 and $550 in the US for a dental without overnight hospitalization.
 +
A dental normally is an outpatient procedure and, barring complications, your pet should come home the same day. The cost of the procedure can vary widely depending on the clinic and the number of extractions, but you can expect to pay between $250 and $1000 in the US for a dental without overnight hospitalization.
   
−
The veterinarian will send you and your pet home with aftercare instructions concerning feeding, antibiotics, and pain medication. The veterinarian may also recommend ongoing dental care, such as brushing, anti-plaque gels, dental chews, and annual dental procedures. You can expect your pet to be somewhat alert once you get him or her home, but perhaps less than 100% for a couple of days.
 +
The veterinarian will send you and your pet home with aftercare instructions concerning feeding, antibiotics, and pain medication. The veterinarian may also recommend ongoing dental care, such as brushing, [[Dental_procedure&action=submit#Ongoing_dental_care|anti-plaque gels]], dental chews, and annual dental procedures. You can expect your pet to be somewhat alert once you get him or her home, but perhaps less than 100% for a couple of days.
   
  +
==Pre-procedure==
⚫
'''General anesthesia.''' The current state of veterinary medicine is to use isoflurane gas<ref>[http://en.wikipedia.org/wiki/Isoflurane Wikipedia: Isoflurane Gas]</ref>. The use of the gas makes it easier to wake the animal if there is an emergency situation during the procedure and makes for an easier post-procedure recovery. As part of administering the gas, the veterinarian will place an endotrachial tube into your pet’s airway<ref>[http://www.moorevet.com/Images/Anesthesia/Bag.jpg Photo of Dog Having Dental Cleaning-Inserted Endotracheal Tube Shown]</ref>.
 
  ⚫
'''Pre-procedure testing.''' If your vet has in-clinic lab equipment, your animal may receive a basic blood panel the morning of the dental. (If your vet does not have that equipment or prefers to send blood out to a lab, that will have to be done before the day of the procedure.) That blood panel will give your veterinarian an indication of whether there are physical conditions other than diabetes that need to be considered in performing the procedure. Among other information, the blood panel will provide a blood glucose reading, and blood urea nitrogen (BUN) and creatinine<ref>[http://www.vetmed.wsu.edu/ClientED/lab.aspx WSU--Blood Panel Information]</ref> values to assess kidney health. A T4 test<ref>[http://www.thyroid-info.com/articles/cat-hyper.htm T4 Test for Thyroid Function]</ref> (a thyroid test) also should be run in all cats over 9 years of age prior to going under general anesthesia. Animals with chronic conditions other than diabetes may require more-extensive blood and other testing (such as an echocardiogram or EKG) before undergoing general anesthesia.
   
  +
'''Fluids.''' Some veterinarians may want the caregiver to withhold water from the pet overnight before the procedure. This is generally difficult on and may [[dehydration|dehydrate]] a diabetic animal and you should question such a requirement. Generally, withholding water for more than 2 to 4 hours before the procedure is not necessary.
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'''Fluids.''' Your pet should receive intravenous (IV) fluids<ref>[http://en.wikipedia.org/wiki/Intravenous Wikipedia:intravenous]</ref> before, during, and after the procedure to maintain blood pressure to make sure the kidneys are perfused optimally. The IV line should have a port on it so that it is a catheter in case emergency medications have to be given, for example, if the pet goes into cardiac or respiratory arrest. (Even if a veterinarian is really good at hitting veins, the blood pressure is the first to drop in an emergency situation. That makes it even harder to find a vein.) The IV fluid may contain dextrose, but not a strong enough solution to cause problems for a diabetic animal.
  
   
−
Some veterinarians may want the caregiver to withhold water from the pet overnight before the procedure. This is generally difficult on and may [[dehydration|dehydrate]] a diabetic animal and you should question such a requirement. Generally, withholding water for more than 2 to 4 hours before the procedure is not necessary.
+
'''Food.''' It is common for your veterinarian to ask you to withhold food for approximately 12 hours before the procedure. This is done to make sure the animal does not aspirate food during the procedure.
−  
−
'''Food.''' It is common for your veterinarian to ask you to withhold food for approximately 12 hours before the procedure. This is done to make sure the animal does not aspirate food during the procedure. The veterinarian may want you to minimize the amount of food your pet receives during the 12-24 hours post-procedure.
  
   
 
'''Insulin.''' A cat will receive a normal insulin dose the night before the procedure. The morning of the procedure, it is common to give a cat 1/2 its normal dose. Depending on the individual situation, the veterinarian may or may not give the cat more insulin before it comes home. Consult with the veterinarian whether you should bring the pet’s insulin and syringes into the clinic with you. If you do bring the insulin with the pet, make sure the office completely understands the proper handling of the insulin, and that the pet’s blood glucose should be tested before it receives a shot. Many caregivers prefer not to have the veterinarian’s office give insulin and to wait until the animal is home and eating full meals before again giving insulin.
  
'''Insulin.''' A cat will receive a normal insulin dose the night before the procedure. The morning of the procedure, it is common to give a cat 1/2 its normal dose. Depending on the individual situation, the veterinarian may or may not give the cat more insulin before it comes home. Consult with the veterinarian whether you should bring the pet’s insulin and syringes into the clinic with you. If you do bring the insulin with the pet, make sure the office completely understands the proper handling of the insulin, and that the pet’s blood glucose should be tested before it receives a shot. Many caregivers prefer not to have the veterinarian’s office give insulin and to wait until the animal is home and eating full meals before again giving insulin.
   
  ⚫
'''Antibiotics.''' A dental procedure releases a large amount of bacteria into the animal’s body. Many suggest that because of diabetics may be more susceptible to infection, the animal should receive pre-procedure antibiotic (anywhere from the day before to seven days before the procedure), as well as a seven-day post-procedure course of antibiotics. A common full-spectrum antibiotic given for this purpose is Clavamox; see the further discussion about this antibiotic [[Medication_warnings#Antibiotics|here]]. Note that antibiotics are increasingly ''not'' used pre- or even post-procedure in healthy animals; not only do most animals undergoing a dental not have an underlying infection, but one purpose of a dental is to clear out infection, making post-dental antibiotics unnecessary.
⚫
'''Monitoring vital signs.''' The veterinarian should have appropriate procedures for monitoring the pet’s breathing, blood pressure, and temperature during the procedure.
 
   
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'''Pain medication.''' Some veterinarians will administer pain medication, such as a nerve block, during a dental that involves an extraction. Some caregivers have reported problems with the administration of pain medication while the animal is under general anesthesia because it can depress the animal’s vital signs. Those caregivers suggest that pain medication should only be given, if needed, as the animal is waking up.
 
   
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==During the procedure==
⚫
Some animals that have extractions will require small amounts of pain medication for a few days post-procedure. That medication may be in pill form (such as Butorphanol/Torbutrol)<ref>[http://www.petplace.com/drug-library/butorphanol-tartrate-torbugesic-torbutrol/page1.aspx Butorphanol/Torbutrol]</ref>, or a liquid that can be injected or given by mouth (such as Buprenorphine/Buprenex)<ref>[http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2182 Buprenorphine/Buprenex]</ref>. A liquid form may be better tolerated by an animal that has had several extractions.
  
   
  ⚫
'''General anesthesia.''' The current standard in veterinary medicine is to use isoflurane or sevoflurane gas<ref>[http://en.wikipedia.org/wiki/Isoflurane Wikipedia: Isoflurane Gas]</ref>. The use of the gas makes it easier to wake the animal if there is an emergency situation during the procedure and makes for an easier post-procedure recovery. As part of administering the gas, the veterinarian will place an endotrachial tube into your pet’s airway<ref>[http://web.archive.org/web/20020718181533/http://www.moorevet.com/Images/Anesthesia/Bag.jpg Photo of Dog Having Dental Cleaning-Inserted Endotracheal Tube Shown]</ref><ref>[http://www.peteducation.com/article.cfm?c=0+1302+1478&aid=983 How Anesthetic Gases Work In Animals]</ref><ref>[http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2010/03/02/petscol030210.DTL#ixzz0jj6Qv5HD Making anesthesia safer for pets]</ref>. Note that using an ET tube is a must for a dental--besides a means of administering the anesthesia, it also maintains your pet's airway, making sure it stays clear during the procedure.
⚫
'''Antibiotics.''' A dental procedure releases a large amount of bacteria into the animal’s body. Many suggest that because of the effect of infections on a diabetic animal’s blood glucose levels, the animal should receive pre-procedure antibiotic (anywhere from the day before to seven days before the procedure), as well as a seven-day post-procedure course of antibiotics. A common full-spectrum antibiotic given for this purpose is Clavamox; see the further discussion about this antibiotic [[Medication_warnings#Antibiotics|here]].
 
  +
  +
Make sure to ask who will be monitoring anesthesia. A separate person (not the person doing the procedure) should be monitoring your pet's anesthesia. Also ask about recovery; there should be a technician or assistant assigned to stay with your animal until he or she is awake enough to have the ET tube removed and until your pet's body temperature has normalized.
  +
  +
'''Fluids.''' Your pet should have an IV catheter placed (an IV catheter should ''always'' be placed when general anesthesia is given) and receive intravenous (IV) fluids<ref>[http://en.wikipedia.org/wiki/Intravenous Wikipedia:intravenous]</ref> during the procedure to help maintain blood pressure. Low blood pressure can cause organ and brain damage. Animals with underlying kidney disease may benefit from receiving fluids before and after the procedure; this is something to discuss with your vet. .
  +
  ⚫
'''Monitoring vital signs.''' The veterinarian should have appropriate procedures for monitoring the pet’s breathing, blood pressure, pulse oximetry, heart, and temperature during the procedure.
  +
  +
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==Post-procedure==
  +
'''Pain medication.''' Optimally, the veterinarian will administer a nerve block during a dental that involves an extraction. If not, and if many extractions are expected, alternate pain management (such as the use of IV opioid drugs) should begin at the same time or slightly before the extractions. Getting ahead of the pain means that your pet may need less pain medication later on, and will be generally more comfortable. Waiting until an animal is awake and painful is unnecessary and should not be common practice.
  +
  ⚫
Animals who have extractions will require pain medication for at least a few days post-procedure. (This is not debatable, despite the fact that the cat or dog may behave normally, because the fact that pain is associated with tooth extraction is well established.) That medication may be in pill form (such as tramadol)<ref>[http://www.petplace.com/drug-library/butorphanol-tartrate-torbugesic-torbutrol/page1.aspx Butorphanol/Torbutrol]</ref>, or a liquid that can be injected or given by mouth (such as buprenorphine/Buprenex, or Metacam)<ref>[http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2182 Buprenorphine/Buprenex]</ref>. A liquid form may be better tolerated by an animal that has had several extractions. Common medications include NSAIDs for dogs (drugs such as Metacam, Rimadyl, etc.), opioids (such as buprenorphine) for cats and dogs, or a synthetic opioid (tramadol) for either species. The use of NSAIDs in cats is controversial, and you should discuss the pros and cons with your veterinarian beforehand if that is his or her recommendation.
  +
  +
Butorphanol (brand name Torbuterol) is no longer considered an acceptable pain medication. It is very mild and extremely short-acting.
  +
  +
  +
==Ongoing dental care==
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Before and between dental procedures, swelling and infection can sometimes be reduced, and decay retarded, by brushing pets' teeth with recommended gels.
  +
  +
Sometimes recommended are:
  +
* '''Zinc ascorbate''' gel (e.g. [http://www.addisonlabs.com/OralCleansingGelFAQs.htm Maxi/Guard])
  +
** This is a chemical plaque retardant that slows down tooth decay and gum disease between dental procedures. It's sometimes advertised as "natural".
  +
  +
* '''Chlorhexidine''' (gel, or if unavailable, liquid)
  +
** This disinfectant sometimes comes from your vet flavored for easier acceptance by cats and dogs. It retards gum disease and reduces pain. Not a long-term substitute for a dental procedure but may delay the need for the next one. Chlorhexidine for pets is harder to find now than in the past.
   
⚫
'''Pre-procedure testing.''' If your vet has in-clinic lab equipment, your animal will receive a basic blood panel the morning of the dental. (If your vet does not have that equipment and needs to send blood out to a lab, that will have to be done before the day of the procedure.) That blood panel will give your veterinarian an indication of whether there are physical conditions other than diabetes that need to be considered in performing the procedure. Among other information, the blood panel will provide a blood glucose reading, and blood urea nitrogen (BUN) and creatinine<ref>[http://www.vetmed.wsu.edu/ClientED/lab.asp WSU--Blood Panel Information]</ref> readings to assess kidney health. A T4 test<ref>[http://www.thyroid-info.com/articles/cat-hyper.htm T4 Test for Thyroid Function]</ref> (a thyroid test) also should be run in all cats over 9 years of age prior to going under general anesthesia. Animals with chronic conditions other than diabetes may require more-extensive blood and other testing (such as an electrocardiogram, EKG) before undergoing general anesthesia.
  
   
 
==List of Board-Certified Veterinary Dentists==
  
==List of Board-Certified Veterinary Dentists==
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You should consider asking your veterinarian these questions when planning a dental procedure.
  
You should consider asking your veterinarian these questions when planning a dental procedure.
   
−
'''General'''
+
'''General'''
−
# Will my pet receive a pre-dental blood workup? Will it be a basic blood panel, or will blood need to be sent out in advance to a lab for more-complete values? Is any other pre-procedure testing needed?
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# Will my pet receive a pre-dental blood workup? Will it be an in-house blood panel, or will blood need to be sent out in advance to a lab? Is any other pre-procedure testing needed?
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# Barring complications, will I be able to bring my pet home the same day?
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# Barring complications, will I be able to bring my pet home the same day?
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# How many tooth extractions do you expect?
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# Will you take x-rays before starting, and aftewards as well if there were extractions?
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# Who will do the dental? Who will do the extractions?
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# Do you have someone else monitoring anesthesia, or is the person doing the procedure supposed to try to monitor anesthesia at the same time?
   
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'''Antibiotics'''
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'''Antibiotics'''
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# Will my pet receive pre-procedure antibiotics and if so when?
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# Will my pet receive pre-procedure antibiotics and if so when?
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# Willl my animal need to be on antibiotics afterwards? For how long?
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# What kind of antibiotics do you use? Should I also give my pet a probiotic and if so, which one and how much?
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# What kind of antibiotics do you use? What are the common side effects of this antibiotic? Should I also give my pet a probiotic and if so, which one and how much?
   
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'''General anesthesia'''
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'''General anesthesia'''
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# What general anesthesia will you use on my animal? Will it be isoflurane gas or something else? Will you be inserting an endotracheal tube<ref>[http://www.moorevet.com/Images/Anesthesia/Tube.JPG X-Ray Image-Inserted Endotracheal Tube]</ref>?
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# What general anesthesia will you use on my animal? Will you be inserting an endotracheal tube<ref>[http://web.archive.org/web/20020620090655/http://www.moorevet.com/Images/Anesthesia/Tube.JPG X-Ray Image-Inserted Endotracheal Tube]</ref> and using isoflurane gas?
  +
# What type of drugs do you use for induction (sedation needed in order to place endotracheal tube)?
   
−
'''Fluids'''
+
'''Fluids'''
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# Will my pet receive IV fluids before, during, and after the dental?
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# Will my pet receive IV fluids before, during, and after the dental?
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# Will the IV fluid include dextrose and, if so, how might that affect my pet's blood glucose levels?
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# Will the IV fluid include dextrose and, if so, how might that affect my pet's blood glucose levels?
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# Will a catheter port be placed in the IV line?
 
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# How long before the procedure will my pet be restricted from water by mouth?
  
   
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'''Monitoring'''
+
'''Monitoring'''
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# Will my pet’s blood pressure be monitored during the procedure?
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# Will my pet’s blood pressure be monitored during the procedure?
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# Will you use a pulse oximeter<ref>[http://lungdiseases.about.com/od/glossaryofterms/g/pulse_oximetry.htm Pulse Oximeter--What It Is And Does]</ref><ref>[http://www.provet.co.uk/health/diagnostics/pulseoximetry.htm Explanation of How Pulse Oximetry Measures Oxygen Levels in a Patient's Blood-Provet UK]</ref><ref>[http://www.moorevet.com/Images/Anesthesia/POxC.jpg Photo of Pulse Oximeter Readout-Oxygen is shown at 93%-Heart Rate is 167 and Pulse at 4 "bars" is the strongest possible pulse reading]</ref><ref>[http://www.moorevet.com/Images/Anesthesia/POx.jpg Photo of Canine Dental-The Pulse Oximeter is attached to dog's rear leg.]</ref>or heart monitor<ref>[http://www.moorevet.com/Images/Anesthesia/Steth.jpg Photo of Esophegeal Stethoscope. The probe is inserted in the esophagus while under anesthesia, allowing more sensitive monitoring of the heart.]</ref><ref>[http://www.heska.com/g2/g2_demo.html Heska Vet/Ox Pulse Oximeter-Flash Presentation Allows You to See How It Works]</ref>?
+
# Will you use a pulse oximeter<ref>[http://lungdiseases.about.com/od/glossaryofterms/g/pulse_oximetry.htm Pulse Oximeter--What It Is And Does]</ref><ref>[http://www.provet.co.uk/health/diagnostics/pulseoximetry.htm Explanation of How Pulse Oximetry Measures Oxygen Levels in a Patient's Blood-Provet UK]</ref><ref>[http://web.archive.org/web/20020718183855/http://www.moorevet.com/Images/Anesthesia/POxC.jpg Photo of Pulse Oximeter Readout-Oxygen is shown at 93%-Heart Rate is 167 and Pulse at 4 "bars" is the strongest possible pulse reading]</ref><ref>[http://web.archive.org/web/20020918051949/http://www.moorevet.com/Images/Anesthesia/POx.jpg Photo of Canine Dental-The Pulse Oximeter is attached to dog's rear leg.]</ref>and an ECG heart monitor<ref>[http://web.archive.org/web/20020718184437/http://www.moorevet.com/Images/Anesthesia/Steth.jpg Photo of Esophegeal Stethoscope. The probe is inserted in the esophagus while under anesthesia, allowing more sensitive monitoring of the heart.]</ref><ref>[http://web.archive.org/web/20061029072010/http://www.heska.com/g2/g2_demo.html Heska Vet/Ox Pulse Oximeter-Flash Presentation Allows You to See How It Works]</ref>?
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# How will you monitor and regulate my pet's temperature?
+
# How will you monitor and regulate my pet's temperature?
   
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'''Pain management'''
+
'''Pain management'''
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# When will my pet receive pain killers?
+
# When will my pet receive pain killers?
  +
# What type of pain medication will you prescribe? What are the common side effects of that medication?
   
−
'''Food'''
 +
'''Food and Water'''
−
# What is the protocol for giving my pet food the evening before, the morning of, and after the procedure?
+
# What is the protocol for giving my pet food the evening before, the morning of, and after the procedure?
  +
# What is the latest time before the procedure that my animal can have access to water?
   
−
'''Diabetes-related questions'''
+
'''Diabetes-related questions'''
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# What kind of stability in blood glucose readings should my pet have before you will do a dental?
+
# What kind of stability in blood glucose readings should my pet have before you will do a dental?
−
# What is the protocol for giving my pet insulin the evening before, the morning of, and after the procedure?
+
# What is the protocol for giving my pet insulin the evening before, the morning of, and after the procedure?
 
# How often will you monitor my pet’s blood glucose level at the clinic?
  
# How often will you monitor my pet’s blood glucose level at the clinic?
 
# Will you give my pet insulin after the procedure?
  
# Will you give my pet insulin after the procedure?
  +
   
 
==Further Reading==
  
==Further Reading==
   
−
[[Image:Cat.gif]]
 +
[[Image:Wikicat3.jpg|100px]]
   
 
*[http://www.felinediabetes.com/phorum5/read.php?8,220134 Discussion on the FDMB about a dental procedure without general anesthesia]
  
*[http://www.felinediabetes.com/phorum5/read.php?8,220134 Discussion on the FDMB about a dental procedure without general anesthesia]
Line 82: Line 111:
   
   
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[[Image:Homecat.gif]][[Image:Homedog.gif]]
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[[Image:Wikicat3.jpg|100px]][[Image:Wikidog3.jpg|100px]]
 
*[http://www.dentalvet.com/Default2.htm DentalVet general dental info]
  
*[http://www.dentalvet.com/Default2.htm DentalVet general dental info]
   
 
*[http://clinical.diabetesjournals.org/cgi/content/full/23/4/171?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=insulin&searchid=1&FIRSTINDEX=60&sortspec=relevance&resourcetype=HWCIT Diabetes and Periodontal Infection: Making the Connection Clinical Diabetes 2005]<br> Despite this being an article aimed at people, it gives a sound basis regarding the special dental difficulties of those with diabetes.
  
*[http://clinical.diabetesjournals.org/cgi/content/full/23/4/171?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=insulin&searchid=1&FIRSTINDEX=60&sortspec=relevance&resourcetype=HWCIT Diabetes and Periodontal Infection: Making the Connection Clinical Diabetes 2005]<br> Despite this being an article aimed at people, it gives a sound basis regarding the special dental difficulties of those with diabetes.
  +
*[http://www.peteducation.com/article.cfm?c=0+1302+1478&aid=975 Anesthesia Machines-How They Work]
  +
*[http://www.peteducation.com/article.cfm?c=0+1302+1478&aid=981 Anesthesia, Tranquilizers and Sedation]
  +
*[http://www.peteducation.com/article.cfm?c=0+1302+1478&aid=977 Monitoring the Anesthesized Animal]
   
 
==References==
  
==References==

Latest revision as of 06:07, 22 August 2014

Overview of the Dental Procedure

Many pets, especially older pets, have gingivitis[1] (inflamation of the gums) or periodontis[2] (recession of supporting bone and gingival attachment) and have to undergo a dental procedure to clean plaque and calculus from their teeth and to extract diseased teeth. Although dental procedures are increasingly common on nondiabetic animals, the procedure is especially important to minimize underlying low grade infections in diabetic animals. That infection may be hindering regulation. Some caregivers report lower blood glucose readings after an animal finishes its post-procedure antibiotics.

Because of the extra risks, some veterinarians prefer not to perform a dental procedure on a diabetic animal with high or erratic blood glucose levels unless it is considered an urgent situation. This can create a Catch-22[3] situation because your pet may have very high or erratic blood glucose levels because of dental infection. If you feel this is the case with your animal, you should discuss this with your veterinarian. You also may want to consider consulting a veterinary dental specialist .

A dental procedure requires general anesthesia. General anesthesia poses a risk for any animal (or human), and is a special concern for older or “special needs” animals. Therefore, the caregiver should have a basic understanding of appropriate dental procedures to be able to ask about them beforehand.

A dental normally is an outpatient procedure and, barring complications, your pet should come home the same day. The cost of the procedure can vary widely depending on the clinic and the number of extractions, but you can expect to pay between $250 and $1000 in the US for a dental without overnight hospitalization.

The veterinarian will send you and your pet home with aftercare instructions concerning feeding, antibiotics, and pain medication. The veterinarian may also recommend ongoing dental care, such as brushing, anti-plaque gels, dental chews, and annual dental procedures. You can expect your pet to be somewhat alert once you get him or her home, but perhaps less than 100% for a couple of days.

Pre-procedure

Pre-procedure testing. If your vet has in-clinic lab equipment, your animal may receive a basic blood panel the morning of the dental. (If your vet does not have that equipment or prefers to send blood out to a lab, that will have to be done before the day of the procedure.) That blood panel will give your veterinarian an indication of whether there are physical conditions other than diabetes that need to be considered in performing the procedure. Among other information, the blood panel will provide a blood glucose reading, and blood urea nitrogen (BUN) and creatinine[4] values to assess kidney health. A T4 test[5] (a thyroid test) also should be run in all cats over 9 years of age prior to going under general anesthesia. Animals with chronic conditions other than diabetes may require more-extensive blood and other testing (such as an echocardiogram or EKG) before undergoing general anesthesia.

Fluids. Some veterinarians may want the caregiver to withhold water from the pet overnight before the procedure. This is generally difficult on and may dehydrate a diabetic animal and you should question such a requirement. Generally, withholding water for more than 2 to 4 hours before the procedure is not necessary.

Food. It is common for your veterinarian to ask you to withhold food for approximately 12 hours before the procedure. This is done to make sure the animal does not aspirate food during the procedure.

Insulin. A cat will receive a normal insulin dose the night before the procedure. The morning of the procedure, it is common to give a cat 1/2 its normal dose. Depending on the individual situation, the veterinarian may or may not give the cat more insulin before it comes home. Consult with the veterinarian whether you should bring the pet’s insulin and syringes into the clinic with you. If you do bring the insulin with the pet, make sure the office completely understands the proper handling of the insulin, and that the pet’s blood glucose should be tested before it receives a shot. Many caregivers prefer not to have the veterinarian’s office give insulin and to wait until the animal is home and eating full meals before again giving insulin.

Antibiotics. A dental procedure releases a large amount of bacteria into the animal’s body. Many suggest that because of diabetics may be more susceptible to infection, the animal should receive pre-procedure antibiotic (anywhere from the day before to seven days before the procedure), as well as a seven-day post-procedure course of antibiotics. A common full-spectrum antibiotic given for this purpose is Clavamox; see the further discussion about this antibiotic here. Note that antibiotics are increasingly not used pre- or even post-procedure in healthy animals; not only do most animals undergoing a dental not have an underlying infection, but one purpose of a dental is to clear out infection, making post-dental antibiotics unnecessary.


During the procedure

General anesthesia. The current standard in veterinary medicine is to use isoflurane or sevoflurane gas[6]. The use of the gas makes it easier to wake the animal if there is an emergency situation during the procedure and makes for an easier post-procedure recovery. As part of administering the gas, the veterinarian will place an endotrachial tube into your pet’s airway[7][8][9]. Note that using an ET tube is a must for a dental--besides a means of administering the anesthesia, it also maintains your pet's airway, making sure it stays clear during the procedure.

Make sure to ask who will be monitoring anesthesia. A separate person (not the person doing the procedure) should be monitoring your pet's anesthesia. Also ask about recovery; there should be a technician or assistant assigned to stay with your animal until he or she is awake enough to have the ET tube removed and until your pet's body temperature has normalized.

Fluids. Your pet should have an IV catheter placed (an IV catheter should always be placed when general anesthesia is given) and receive intravenous (IV) fluids[10] during the procedure to help maintain blood pressure. Low blood pressure can cause organ and brain damage. Animals with underlying kidney disease may benefit from receiving fluids before and after the procedure; this is something to discuss with your vet. .

Monitoring vital signs. The veterinarian should have appropriate procedures for monitoring the pet’s breathing, blood pressure, pulse oximetry, heart, and temperature during the procedure.


Post-procedure

Pain medication. Optimally, the veterinarian will administer a nerve block during a dental that involves an extraction. If not, and if many extractions are expected, alternate pain management (such as the use of IV opioid drugs) should begin at the same time or slightly before the extractions. Getting ahead of the pain means that your pet may need less pain medication later on, and will be generally more comfortable. Waiting until an animal is awake and painful is unnecessary and should not be common practice.

Animals who have extractions will require pain medication for at least a few days post-procedure. (This is not debatable, despite the fact that the cat or dog may behave normally, because the fact that pain is associated with tooth extraction is well established.) That medication may be in pill form (such as tramadol)[11], or a liquid that can be injected or given by mouth (such as buprenorphine/Buprenex, or Metacam)[12]. A liquid form may be better tolerated by an animal that has had several extractions. Common medications include NSAIDs for dogs (drugs such as Metacam, Rimadyl, etc.), opioids (such as buprenorphine) for cats and dogs, or a synthetic opioid (tramadol) for either species. The use of NSAIDs in cats is controversial, and you should discuss the pros and cons with your veterinarian beforehand if that is his or her recommendation.

Butorphanol (brand name Torbuterol) is no longer considered an acceptable pain medication. It is very mild and extremely short-acting.


Ongoing dental care

Before and between dental procedures, swelling and infection can sometimes be reduced, and decay retarded, by brushing pets' teeth with recommended gels.

Sometimes recommended are:

  • Zinc ascorbate gel (e.g. Maxi/Guard)
    • This is a chemical plaque retardant that slows down tooth decay and gum disease between dental procedures. It's sometimes advertised as "natural".
  • Chlorhexidine (gel, or if unavailable, liquid)
    • This disinfectant sometimes comes from your vet flavored for easier acceptance by cats and dogs. It retards gum disease and reduces pain. Not a long-term substitute for a dental procedure but may delay the need for the next one. Chlorhexidine for pets is harder to find now than in the past.


List of Board-Certified Veterinary Dentists

Questions to Ask Veterinarians about Dental Procedures

You should consider asking your veterinarian these questions when planning a dental procedure.

General

  1. Will my pet receive a pre-dental blood workup? Will it be an in-house blood panel, or will blood need to be sent out in advance to a lab? Is any other pre-procedure testing needed?
  2. Barring complications, will I be able to bring my pet home the same day?
  3. How many tooth extractions do you expect?
  4. Will you take x-rays before starting, and aftewards as well if there were extractions?
  5. Who will do the dental? Who will do the extractions?
  6. Do you have someone else monitoring anesthesia, or is the person doing the procedure supposed to try to monitor anesthesia at the same time?

Antibiotics

  1. Will my pet receive pre-procedure antibiotics and if so when?
  2. Willl my animal need to be on antibiotics afterwards? For how long?
  3. What kind of antibiotics do you use? What are the common side effects of this antibiotic? Should I also give my pet a probiotic and if so, which one and how much?

General anesthesia

  1. What general anesthesia will you use on my animal? Will you be inserting an endotracheal tube[13] and using isoflurane gas?
  2. What type of drugs do you use for induction (sedation needed in order to place endotracheal tube)?

Fluids

  1. Will my pet receive IV fluids before, during, and after the dental?
  2. Will the IV fluid include dextrose and, if so, how might that affect my pet's blood glucose levels?

Monitoring

  1. Will my pet’s blood pressure be monitored during the procedure?
  2. Will you use a pulse oximeter[14][15][16][17]and an ECG heart monitor[18][19]?
  3. How will you monitor and regulate my pet's temperature?

Pain management

  1. When will my pet receive pain killers?
  2. What type of pain medication will you prescribe? What are the common side effects of that medication?

Food and Water

  1. What is the protocol for giving my pet food the evening before, the morning of, and after the procedure?
  2. What is the latest time before the procedure that my animal can have access to water?

Diabetes-related questions

  1. What kind of stability in blood glucose readings should my pet have before you will do a dental?
  2. What is the protocol for giving my pet insulin the evening before, the morning of, and after the procedure?
  3. How often will you monitor my pet’s blood glucose level at the clinic?
  4. Will you give my pet insulin after the procedure?


Further Reading

Wikicat3


Wikicat3Wikidog3

References

  1. ↑ Gingivitis
  2. ↑ Periodontis
  3. ↑ Wikipedia: Catch-22
  4. ↑ WSU--Blood Panel Information
  5. ↑ T4 Test for Thyroid Function
  6. ↑ Wikipedia: Isoflurane Gas
  7. ↑ Photo of Dog Having Dental Cleaning-Inserted Endotracheal Tube Shown
  8. ↑ How Anesthetic Gases Work In Animals
  9. ↑ Making anesthesia safer for pets
  10. ↑ Wikipedia:intravenous
  11. ↑ Butorphanol/Torbutrol
  12. ↑ Buprenorphine/Buprenex
  13. ↑ X-Ray Image-Inserted Endotracheal Tube
  14. ↑ Pulse Oximeter--What It Is And Does
  15. ↑ Explanation of How Pulse Oximetry Measures Oxygen Levels in a Patient's Blood-Provet UK
  16. ↑ Photo of Pulse Oximeter Readout-Oxygen is shown at 93%-Heart Rate is 167 and Pulse at 4 "bars" is the strongest possible pulse reading
  17. ↑ Photo of Canine Dental-The Pulse Oximeter is attached to dog's rear leg.
  18. ↑ Photo of Esophegeal Stethoscope. The probe is inserted in the esophagus while under anesthesia, allowing more sensitive monitoring of the heart.
  19. ↑ Heska Vet/Ox Pulse Oximeter-Flash Presentation Allows You to See How It Works
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