Dr. Bill Wagner
Be a Dental Health Hero
This week is a bit of a treat for me because I LOVE talking about the extensive medical benefits of being an advocate for proactive dental health in our patients. There are precious few opportunities that we have as veterinarians to do so much good for our patients all at once as we do by preventing and treating periodontal disease. Dental health is a difficult topic for veterinarians, as appropriate interventional dental care requires general anesthesia in small animal patients which inevitably leads to challenging conversations with clients about cost of care and anesthetic risk.
The medical side:
Dental disease is one of the most prevalent and impactful diseases of small animal patients. By two years of age 80% of dogs and 70% of cats have some form of periodontal disease, with small breed dogs being overrepresented. The local impact of periodontal disease is the easiest to recognize: Dental pain, mobility and loss of teeth, cavities, oronasal fistulas, tooth root abscesses, and even in severe cases pathologic fractures of the jaw.
The systemic impact of periodontal disease is more insidious but no less concerning: The significant bacterial burden and pro-inflammatory effects of dental disease negatively affect the entire body, with the heart, liver, and kidneys most likely to develop disease as sequelae of dental disease.
Importantly, dental disease is highly preventable and treatable. A thorough oral examination at least yearly as part of a comprehensive annual physical examination is critical in identifying existing disease and discussing preventative and interventional oral health with clients.
Periodontal disease is also not the only disease of the mouth that can develop, as other pathologies such as oral cancers can occur in pets of any age and breed.
A thorough annual oral exam can catch the early onset of a multitude of other issues.
Put simply: Talking with every one of your clients at least once a year about their pet’s individual oral health is a key piece of practicing gold standard medicine. Recommending dental prophylaxis at appropriate timing for each patient before severe dental pathology arises may add literal years to their lives.
Dental radiography is increasingly becoming part of the standard of care for all dental procedures regardless of the level of visible pathology above the gum line. With ~60% of the tooth lying below the gum line and our small animal patients being predisposed to subgingival pathology (especially cats), it simply isn’t possible to do a thorough assessment of a patient’s oral health with just your eyes and a dental probe. Routinely performing dental radiography with every dentistry significantly increases the quality of care that you’re providing to your patients (and by extension, the value to your clients – more on that later) as well as reducing personal liability around issues such as missed pathology or incomplete extractions.
Understanding when to refer is also a difficult but important discussion. Like any area of general practice, severe or otherwise complicated cases of dental disease can overwhelm our ability as GPs to provide the best possible care. Developing relationships with your local dental specialists not only sets the stage for conversation about future cases that you will refer, but also provides you with a sounding board for what cases the specialists feel are or aren’t appropriate for referral.
When in doubt, making clients aware that specialist referral is an option is always important so that they can have a complete picture of their choices for their pet’s care.
Anesthetic risk is a critical topic to cover in conversations prior to scheduling a patient for a dental procedure. Anesthetic risk is quite low for well-managed anesthesia in a patient without other underlying health concerns. However, many patients with dental disease are older and dental disease itself can leave them predisposed to having issues that complicate their anesthetic risk (particularly diseases of the heart, liver, and/or kidneys). Patient screening and selection is a critical part of safe dentistry. Referral for supervision by a board-certified anesthesiologist is always a good option to consider for higher risk patients, and owners should always be fully educated about risks and options and sign a consent form prior to pursuing general anesthesia.
The financial side:
As with all that we do as veterinarians and business owners we must balance our competing ethical responsibilities to all the parties who we serve. We have a responsibility as veterinarians to ensure that we price our services such that we do not reduce the access of responsible pet owners to medical care for their pets. We also have a responsibility as business owners to ensure that all who eat at the shared table of our business (including ourselves and our team members) do not go hungry because of subsidizing the true cost of veterinary healthcare out of the pockets of the veterinary workforce.
Good dentistry is time consuming, requires significant utilization of a veterinarian’s and technician’s skills, and is a medical intervention that provides dramatic and nearly immediate improvement to a pet’s health. Those are all things that add up to a service that should be priced to match the large value provided to the client and the large cost to the clinic. However, most clients likely haven’t budgeted for what the true cost of what good dentistry is. This has resulted in many clinics not pricing dentistry appropriately, turning it into a break-even procedure or even a loss leader to their own detriment.
Here’s a few ways to help communicate and price dentistry more effectively:
Itemize your invoices and thoroughly explain them by line item to clients.
Rather than using a single “bulk charge” approach, it is much easier for clients to understand the value (and by extension, the cost) of the care that was provided to arrive at the final number on their invoice. Things like preoperative bloodwork, pain control, dental radiographs, anesthetic time, anesthetic monitoring, and intraoperative intravenous fluids all are important and value-creating parts of a thorough dentistry procedure and should have their own itemized charges. Both at the time of providing the initial treatment plan and at the time of discharge the invoice should be reviewed with the client by line item to explain what was done, regardless of whether the client has previously communicated cost concerns. The work you do is valuable, but clients won’t understand the full extent of the value they’ve received unless it is explained to them.
Continuing education is a great opportunity to increase the value of dentistry for your clinic.
The practice of medicine is truly that: Ongoing practice. We are always learning and improving and taking the time to pursue continued study in any area of medicine will help you work more effectively and thoroughly. Dentistry is no exception. Continuing education is an excellent opportunity to improve speed in technical proficiencies such as extractions and obtaining good radiographs, reduce time-consuming errors such as broken roots during extraction, and improve your ability to identify and address pathology. Doing better work faster translates into better outcomes for your patients, less anesthetic time (and by extension, lower anesthetic complication rates), and the ability to safely schedule more procedures per surgical block without compromising quality of care.
Education about dental health should start at puppyhood/kittenhood.
The first time that clients are hearing about their pet’s dental health shouldn’t be when there’s already pathology to address and a dentistry to schedule. Setting expectations about anticipated future dental health expenses sets clients up for success in budgeting. Obviously, whether clients choose to save for future expenses is out of your control but equipping them with the knowledge that their puppy or kitten will have expenses related to their dental health in the future means that at least you’ve done your part. Dental health expenses should not be a surprise for your long-term clients!
Clear communication and correct pricing will show value. Dentistry can be the ideal intersection of good medicine and good business.
Having frequent, clear, and proactive conversations with clients to establish realistic expectations before intervention is necessary and making sure that you’re communicating and pricing appropriately to match the value provided are the keys to learning to love dentistry!
That will bring a smile to anyone’s face.