World Small Animal Veterinary Association Global Dental Guidelines Authors: Brook Niemiec DAVDC, DEVDC, FAVD (USA), Jerzy Gawor DAVDC, DEVDC, FAVD (Poland), Ana Nemec DAVDC, DEVDC (Slovenia), David Clarke DAVDC (Australia), Cedric Tutt, DEVDC (South Africa), Marco Gioso DAVDC (Brazil), Paulo Steagall DACVAA (Canada), Marge Chandler DACVN, DACVIM, DECVIM-CA (UK), Gottfried Morgenegg (Switzerland), Rod Jouppi (Canada), Kymberley Stewart (Canada) Abstract Dental, oral, and maxillofacial diseases are one of the most common problems in small animal veterinary practice. These conditions create significant pain as well as localized and potentially systemic infection. As such, the World Small Animal Veterinary Association (WSAVA) believes that un- and under treated oral and dental diseases pose a significant animal welfare concern. Dentistry is an area of veterinary medicine which is still widely ignored and is subject to many myths and misconceptions. Effective teaching of veterinary dentistry in the veterinary school is the key to progression in this field of veterinary medicine, and to the improvement of welfare for all our patients globally. These guidelines were developed to provide veterinarians with the information required to understand best practices for dental therapy and create realistic minimum standards of care. Using the three-tiered continuing education system of WSAVA, the guidelines make global equipment and therapeutic recommendations and highlight the anaesthetic and welfare requirements for small animal patients. This document contains information on common oral and dental pathologies, diagnostic procedures (an easily implementable and repeatable scoring system for dental health, dental radiography and radiology) and treatments (periodontal therapy, extractions). Further, there are sections on anaesthesia and pain management for dental procedures, home dental care, nutritional information, and recommendations on the role of the universities in improving veterinary dentistry. A discussion of the deleterious effects of anaesthesia free dentistry (AFD) is included, as this procedure is ineffective at best and damaging at worst. Throughout the document the negative effects of undiagnosed and/or treated dental disease on the health and well-being of our patients, and how this equates to an animal welfare issue, is discussed. Introduction The World Small Animal Veterinary Association (WSAVA) is an ‘association of associations’ with over 200,000 small animal veterinarians globally represented by over 101 member associations. Utilizing guidelines assists the entire healthcare team to understand, embrace, and enact practice standards to improve quality of care for all patients. Like those before it, the Global Dental Standardization Guidelines committee was established to develop a universally relevant document that would take into consideration the world-wide differences in educational background, access to equipment and drugs, as well as treatment modalities of its members. The guidelines committee encompasses members from diverse veterinary specialties, emphasizing the multimodal approach necessary to provide proper dental health services. Authors representing advanced training in dentistry, nutrition, anaesthesia, 1 analgesia, and animal welfare have come together to each highlight the importance of oral and dental diseases treatment and prevention for our patients from various areas of veterinary care. The WSAVA sincerely hopes these guidelines will empower members of the global healthcare team to recognize and treat oral and dental diseases, further promote and guide inclusion of dentistry in the veterinary university curriculum, and increase the level of confidence in the need for proper veterinary dental care for patients worldwide. Use of this document Oral and dental diseases know no geographical boundaries, and as such the guidelines were developed to assist practitioners from around the world. The only limiting factors to proper dental therapy are awareness of its prevalence or impact on patient health and welfare, education on the subject, and a commitment to include oral and dental assessment in every physical examination. These guidelines were created with easy to implement fundamentals at their core. Their purpose is to guide the general practitioner towards successful detection, diagnosis and therapy of the most common oral and dental conditions. While continued research is required in all areas represented in these guidelines, a distinct effort has been made to provide peer reviewed evidence-based recommendations in all areas. Where veterinary dental research is unavailable or lacking, additional human dental literature may be cited. Each section contains an extensive reference list should the practitioner require additional information. There is additional reference material available on the WSAVA website (www.wsava.org). Throughout this document, the WSAVA’s continuing education three-tiered system has been utilized to make recommendations for the various member associations. It is understood that even within countries, there is great variability in standards of care, and this document should be viewed as it was intended, as guidelines to improve dental care. Tiering where appropriate should be used to guide the practitioner to minimum acceptable practices in their represented countries, but is by no means meant to recommend an interested practitioner stop there in their provision of service, or pursuit of educational goals. Tier 3 could also be considered best practice internationally, Tier 2 minimal standard in a less economically developed country, and falling below the Tier 1 standard unacceptable anywhere in the world. Acknowledgement of the vast differences in the availability of analgesic and anaesthetic drugs is made, and practitioners are guided to the Global Pain Council’s guidelines (2013) available in JSAP and on the WSAVA website for further guidance. 2 Table of Contents Section 1: Oral Anatomy and Common Pathology ................................................................... 4 a. Oral and Dental Anatomy and physiology ...................................................................... 4 b. Periodontal Disease .......................................................................................................... 7 c. Common Disorders of the Teeth .................................................................................... 13 d. Tooth Resorption ........................................................................................................... 16 e. Maxillofacial Trauma ..................................................................................................... 20 f. Oral Tumours ................................................................................................................ 24 g. Malocclusions ............................................................................................................... 30 Section 2: Animal Welfare Issues Concerning Dental health ................................................. 32 Section 3: Anaesthesia and Pain Management ......................................................................... 37 a. Statement on Anaesthesia Free Dentistry (AFD) ........................................................... 35 Section 4: Oral Examination and Recording ........................................................................... 48 Section 5: Periodontal Therapy ................................................................................................. 53 a. Basic Periodontal Therapy ............................................................................................. 53 b. Dental Homecare ........................................................................................................... 61 i. Active Homecare ............................................................................................... 62 ii. Passive Homecare .............................................................................................. 64 Section 6: Dental Radiology ........................................................................................................ 70 Section 7: Dental Extractions .................................................................................................... 73 Section 8: The University’s Role in Dental Education ............................................................ 80 Section 9: The WSAVA’s Position on Non Anaesthetic Dentistry .......................................... 82 Section 10: Necessary Equipment ............................................................................................. 84 Section 11: References ................................................................................................................ 92 3 Section 1: Oral Anatomy and Common Pathology Oral and Dental Anatomy and Physiology Bones of the maxilla and mandible The upper jaw consists of paired maxillae and incisive bones. Their alveolar processes contain alveoli for the incisor (incisive bone), canine, premolar and molar teeth (maxillary bone). (Figure 1) The lower jaw is formed by the two mandibles which are joined at the symphysis. Each mandible has a body with the alveoli for incisor, canine, premolar and molar teeth, and a ramus consisting of the angular, coronoid and condylar processes. The condylar process of the mandibular ramus articulates with the temporal bone at the temporomandibular joint (Lewis and Reiter, 2010; Evans and de Lahunta, 2013).