Dental procedure

Overview of the Dental Procedure

Many pets, especially older pets, have gingivitis (inflamation of the gums) or periodontis (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 situation because your pet may have very high or erratic blood glucose levels because of dental infection. This is a vicious circle situation that you should discuss 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, 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.

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 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 readings to assess kidney health. A T4 test (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.

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. 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.

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 here.

During the procedure

General anesthesia. The current state of veterinary medicine is to use isoflurane gas. 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.

Fluids. Your pet should receive intravenous (IV) fluids 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.

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

Post-procedure

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.

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), or a liquid that can be injected or given by mouth (such as Buprenorphine/Buprenex). A liquid form may be better tolerated by an animal that has had several extractions.

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

• AVDC list

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 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?
2. Barring complications, will I be able to bring my pet home the same day?

Antibiotics

1. Will my pet receive pre-procedure antibiotics and if so when?
2. What kind of antibiotics do you use? 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 it be isoflurane gas or something else? Will you be inserting an 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?
3. Will a catheter port be placed in the IV line?
4. How long before the procedure will my pet be restricted from water by mouth?

Monitoring

1. Will my pet’s blood pressure be monitored during the procedure?
2. Will you use a pulse oximeteror heart monitor?
3. How will you monitor and regulate my pet's temperature?

Pain management

1. When will my pet receive pain killers?

Food

1. What is the protocol for giving my pet food the evening before, the morning of, and after the procedure?

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

• Discussion on the FDMB about a dental procedure without general anesthesia
• Veterinary page on chronic gum inflammation
• Gorbzilla reference on dental procedures
• Feline Dentistry-Feline Advisory Board

• DentalVet general dental info

• Diabetes and Periodontal Infection: Making the Connection Clinical Diabetes 2005
  Despite this being an article aimed at people, it gives a sound basis regarding the special dental difficulties of those with diabetes.
• Anesthesia Machines-How They Work
• Anesthesia, Tranquilizers and Sedation
• Monitoring the Anesthesized Animal