Dental disease is considered one of the top three conditions causing significant welfare issues for our pet population within the UK. The other two conditions sitting alongside dental disease include ostearthritis and otitis both of which need considerable input from the clinician in terms of communication and treatment in order to offer the most successful outcome. This is also the case for dental disease which in itself includes a number of different conditions such as gingivitis/stomatitis in cats, FORLs, malocclusions, periodental disease to name just a few. In order to improve the outcome of surgery for these patients successful implementation of the three stages of surgery, pre-operative, intra-operative and post-operative must be achieved. This was the advice of Andrew Perry BVSc DipEVDC MRCVS EBVS who led last week’s webinar and extensively covered multiple aspects of oral surgery.
Andrew offered a number of top tips on how to best manage these patients. Communication is obviously key when you first meet these patients and one initial piece of advice delivered by Andrew was to state, if necessary, that treatment may require long term management and it may be necessary to split any dental/oral treatment into two or three procedures. If it is thought that a procedure is going to take longer than 1-2 hours (which ,lets face it, with many dentals this is often the case) it certainly may well be more beneficial to split this into two shorter procedures where general anaesthesia is likely to be better tolerated. Another obvious aim for improving outcomes of surgery is to minimise a patient’s physiological and psychological stress in order to minimise the risks of catecholamine induced cardiac incidents. There are some simple steps to help achieve this by, for example, sedating patients whilst still with their owners. Andrew also finds gabapentin particularly useful in cats as a pre-operative anxiolytic where a 100mg dose of gabapentin is given per cat 1-2 hours prior to handling.
Intra-operative support can be achieved by administering fluid therapy especially for longer procedures and monitoring blood pressure to ensure hypotension does not develop. The risk of hypotension can be minimised by reducing the use of inhalational anaesthesia by utilising additional analgesia and delivering boluses of iv fluids (5-10ml/kg over a 10 minute period) when hypotension does develop. Ketamine can also be useful as it is an analgesic and positive inotrope. Intra-operetive antibiotic use should also be considered where co-morbidities exist such as heart disease, renal disease or where there is the presence of an orthopaedic implant. The AVDC’s position statement advocates intra-operative use of antibiotics under these circumstances and Andrew advises administering intravenous potentiated amoxycillin every 90-120 minutes which is then discontinued on recovery. The AVDC ,however, only advocates the use of antibiotics post operatively if severe infection is present. They also stated that antibiotics are never useful as a monotherapy as the bacteria present in plaque will be resistant to the effects of antibiotics. Analgesia is also an extremely important consideration during the pre, intra and post operative periods and can be acheived by utilising a combination of drugs including NSAIDs, amantadine, gabapentin, ketamine and opiates. There are some conditions such as feline gingivitis/stomatitis or feline orofacial syndrome where these drugs need to be used in combination for several months.
Andrew also wanted to explain how important applied radiology can be in these cases. He even admitted to not really enjoying dental surgery until oral radiology became available. Andrew found it proved invaluable for technique selection and implementation as well as diagnosis. As an example of its value, Andrew explained that the maxillary third premolar is usually a two rooted tooth but in 10% of cases there will be an accessory root explaining why, in some cases, it can seem very challenging to extract this tooth. However if x-rays had been performed the accessory root could be visualised and taken into account when the extraction is performed. It can also help in deciding whether a crown amputation or root extraction is necessary in cases of extensive tooth resorption.
Andrew went on to discuss a number of techniques utilised for regional anaesthesia including the mandibular nerve block, the infra-orbital block and the maxillary nerve block. He also discussed dental surgical techniques including design and elevation of the muco-periosteal flap. I wouldn’t even attempt to try and explain these within this blog as it is a must to see these techniques demonstrated within the context of this webinar where visual aids are crucial to their understanding. It is for this reason that I would highly recommend logging into this webinar and learning how to safely perform these techniques as well as further understanding how to achieve the most successful outcome in these oral surgeries.
If you would like to watch this webinar, you can see it now by clicking here.