No Mess, No Fuss – Achieving a Successful Dental: Part Two

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No mess, no fuss – achieving a successful dental: part two

Author : Claire Bloor

Categories : RVNs

Date : August 1, 2012

In part one of this article (VNTimes 12.07) the essentials of preoperative planning in order to execute a quality “routine” dental was discussed. Part two will explore the intra and postoperative periods.

Intraoperative period

Having dealt with the preoperative considerations and concerns in part one, we can now turn to the intraoperative period. The veterinary nurse should address all of the following points to ensure a successful outcome for any routine dental procedure:

anaesthetic drugs analgesia monitoring and support room and equipment set up and preparation – including patient preparation

The procedure

The choice of anaesthetic drugs and protocol followed is the remit of the veterinary surgeon. The VN may draw up and administer premedication drugs when directed to by the VS, and also administer set doses of anaesthetic induction drugs, such as triple combinations, when instructed. The induction of anaesthesia using drugs incrementally to effect should only be performed by a VS.

Analgesia is an essential consideration for any dental – and any surgical – patient, because tissue manipulation will result in a degree of inflammation, no matter how gently the tissues are handled, which will result in pain (Gaynor and Muir, 2002). It is advisable to incorporate analgesia into the premedication, which tends to be a routine scenario in most practices where a neuroleptanalgesic mixture is administered – such as a phenothiazine derivative for sedation plus an opioid for analgesia.

1 / 6 If a patient is deemed healthy enough during preoperative checks, the VS will usually request that an NSAID is also administered, so the patient has centrally acting analgesia (the opioid) as well as peripherally acting analgesia from the NSAID activity. A multimodal approach to analgesia should be encouraged in all patients (Challis and Seymour, 2008). Using two or more types of analgesic in combination, as described above, can be further enhanced in dental patients with the use of local anaesthetic nerve blocks.

Veterinary oral and maxillofacial surgeons are available throughout the UK if a VS wants further advice about performing nerve blocks. Veterinary nurses should be aware of the longevity of action of the analgesic drugs they are administering, and ideally devise an analgesic regime with the VS prior to the procedure so the patient is “topped-up” appropriately, especially during lengthy procedures and into the postoperative period.

Monitoring

A “routine dental” cannot be deemed successful if a patient dies while under general anaesthesia – therefore, it is imperative the patient is monitored as vigilantly as during any other surgical procedure to evaluate the depth of anaesthesia, and also maintain optimal cardiovascular and respiratory function.

It was mentioned in part one that intravenous fluid therapy (IVFT) is preferable in all dental patients (when indicated), which should also be monitored with regards to the rate of administration and its effects (Milella, 2012).

Noninvasive blood pressure monitoring should be available in most general practices, whereas central venous pressure monitoring tends to be less common due to practices not having the equipment and/or being less familiar with the technique.

A key thing to remember at this point is that the patient should be monitored at all times. The VN may be heavily involved in the actual dental procedure itself, be it with the probing and charting, scaling and polishing, taking radiographs, sectioning of multirooted teeth in preparation for extraction, and so on, and if this is the case someone else must be involved in the surgery to monitor the patient. It is not wise for the VS to induce the anaesthetic and then leave the VN to do all of the preparatory work and expect him or her to effectively monitor the patient at the same time.

Preparation

Advanced preparation of the dental room and equipment can make the whole procedure much more comfortable and enjoyable for all concerned (Figure 1).

Performing dentistry on a tub-table is far from ideal because the height cannot be adjusted to suit the operator. If many routine dental procedures are performed at a tub-table, someone is going to

2 / 6 develop some form of repetitive strain injury or postural problems (DeForge, 2002; Aller, 2005).

The VN should set up for a dental on a normal operating table with some form of tray to catch fluid and debris. There should also be a heat pad on the table, Vetbed, a rolled-up towel to place under the patient’s shoulders to aid postural drainage (and reduce the likelihood of aspiration), and a blanket to place over the patient.

Other means of warming the patient should also be employed to prevent hypothermia, such as wrapping the extremities in bubble wrap, using a space blanket or an active warming device, such as a Bair Hugger. The patient may also be pre-warmed before induction. Hypothermia is, unfortunately, a very common occurrence during surgery, especially lengthy procedures – such as dentals – and every effort should be made to maintain normothermia; therefore, regular temperature monitoring is essential.

Equipment

The VS or operator should have an appropriate stool to sit on for the procedure, preferably one on five wheels for optimal stability. A good operating light is essential, preferably wallmounted, to reduce the amount of floor space used (Figure 2). Around the table there will already be the dental machine, radiography machine and instrument trolley to accommodate, and potentially an anaesthetic machine. A wall-mounted anaesthetic machine is ideal and reduces clutter (Figure 3).

The dental machine should be handy for the operator and have the foot controls positioned in an appropriate and convenient place.

The instrument trolley should also be within easy reach to prevent the need for twisting, bending and stretching to reach the equipment (Figure 4). The trolley should be prepared with all the equipment the operator is likely to need throughout the procedure, and should be organised and tidy (Figure 5). The instruments should have been checked prior to the procedure to ensure they are all in good working order.

Equipment required for induction, intubation and airway preparation should be prepared in advance, including the induction agent, intravenous access equipment, IVFT equipment, appropriately sized endotracheal (ET) tubes with cuffs, ET tube ties, local anaesthetic sprays, anaesthetic circuits and throat packs. Some people do not like to use throat packs in case they are accidentally left in situ and then aspirated by the recovering patient; however, they are good for trapping debris during the procedure and preventing it from entering the larynx and trachea. Throat packs should be removed regularly, the water squeezed out and then replaced if they are to be of any benefit. It is advisable to actually tie them to the patient’s ET tube so they cannot be forgotten about (Milella, 2012).

Postoperative period

3 / 6 A successful routine dental does not end when the anaesthetic does; it is essential both the patient and owner are managed well after the treatment. The elements the VN must consider in this period include:

immediate postoperative care discharge advice and information follow-up and home care regimes

Initially, the patient must be recovered from anaesthesia, and immediate postoperative care will involve close monitoring of a patient’s vital signs, maintenance of IVFT until it is fully recovered and, ideally, has eaten and drunk of its own volition, monitoring for any (excessive) bleeding from the oral cavity (blood-tinged saliva is likely and, essentially, normal), and the continuation of analgesic medication.

The patient should be offered fresh water and food once recovered because it will have been starved of both prior to the anaesthetic, and we need to make sure it is at least willing to eat something before sending it home. Something like chicken or white fish should be fed for the first few days (maybe up to a week depending on the number of extractions) while initial healing takes place. We do not want sticky, soft foods accumulating around the sutures or inside the sockets where teeth have been removed. Always bear in mind that the diet must provide sufficient calories to maintain the patient and promote healing (Milella, 2012).

Owners should be advised about potential problems at discharge so they understand why they should be feeding the chicken or white fish, and appreciate that blood-tinged saliva is normal, but frank blood is abnormal.

Discharge advice should be provided both in written form and verbally, along with an explanation of the patient’s dental chart (Figure 6), which often helps owners visualise which teeth have been removed and, more importantly, appreciate why they were removed. You should also discuss home care at this point; if only a few teeth required extraction, the owner could start tooth brushing immediately and simply avoid the areas where the teeth have been removed. If a patient had multiple extractions, the owner could start using a chlorhexidine oral rinse every 12 hours until the gingiva are suitably healed and tooth brushing can commence.

Postoperative checkups

An appointment should be booked for an initial postoperative check around two to three days postsurgery to assess initial healing. The owners’ initial home care efforts can be checked at this point too. During this appointment it should be explained to the owners again exactly what their pet had done during the procedure, as they may not have taken in all of this information during the initial discharge. Offer further home care advice and reiterate the importance of oral hygiene for the pet – if they do nothing to maintain their pet’s remaining teeth, remind them that another “routine

4 / 6 dental” procedure is likely to be required within the next couple of years.

The final postoperative check should be performed around two weeks after surgery, again to check healing and assess home care efforts. The VN should discuss home care once again at this point (can you tell that repetition is a useful tool to encourage compliance?), and encourage a return to the dental clinic each time a reminder is sent.

I believe it is wise to request they attend every month to assess the patient’s oral cavity, and the time intervals can then be increased according to their success – or otherwise – with the recommended oral home care regime.

Conclusions

There are many considerations for the VN in relation to best practice and successful “routine dentistry”. The success of any dental procedure cannot just be judged on the outcome of the surgery; the lasting effects and benefits to the patient and its improved health must also be considered when determining success.

As mentioned previously, a routine dental should not be declared a success when the anaesthetic is turned off, but the following elements should also be included:

assessment and preparation of the patient a well-planned, balanced and managed anaesthetic an informed and compliant client a well-prepared, organised and maintained operating theatre well-maintained equipment appropriate surgical after care, follow-up appointments and home care regimes

References

Aller M A (2005). Personal Safety and Ergonomics in the Dental Operatory, Journal of Veterinary Dentistry, 22(2): 124-127. Challis K and Seymour C (2008). Advanced anaesthesia and analgesia In: Hotston Moore A and Rudd S (eds), BSAVA Manual of Canine and Feline Advanced Veterinary Nursing (2nd edn), BSAVA, Gloucester. DeForge D H (2002). Physical Ergonomics in Veterinary Dentistry, Journal of Veterinary Dentistry, 19(4): 196-200. Gaynor J S and Muir W W (2002). Handbook of Veterinary Pain Management, Mosby, Missouri. Milella L (2012). Perioperative care, BSAVA Scientific Proceedings Nursing Programme, BSAVA, Gloucester.

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Reviewed by Helen Clarke, BVSc, MRCVS, CertED

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