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Veterinarian Technician December 2011 (Vol 32, No 12)

Dental Checkup: Anesthesia of Dental Patients

by Annie Mills, LVT, VTS (Dentistry)

    CETEST This course is approved for 1.0 CE credits

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    A typical surgery day in a general veterinary practice usually consists of routine elective procedures such as spaying, neutering, and declawing. The risks of anesthesia are discussed with clients, most of whom are willing to proceed because they understand that the risks are minimal. Even in life-threatening situations that require anesthesia and surgery for pets, clients may be more preoccupied with the risks of the potentially life-saving surgery than with the risks of anesthesia.

    Dental disease is not usually immediately life-threatening, and some dental procedures are considered to be elective, but not routine. For example, yearly dental cleanings can often turn into more involved procedures, including periodontal therapy, restorative dental therapy, or dental extractions.

    The risk of anesthesia can be much greater in senior patients than in young patients because the former may have additional health issues. Therefore, it can be difficult to obtain client consent to proceed with dental procedures for senior pets. Although cost can sometimes be a factor in a client’s decision, the fear of anesthesia is why most clients decline professional dental care for their pets.a However, clients with senior pets may agree to procedures despite extreme apprehension regarding anesthesia.1

    Therefore, veterinary teams should assess their anesthetic protocol and practices and ask themselves the following important questions:

    • Are we doing enough to minimize the risk of anesthesia? If not, how can we improve our dental anesthetic program?

    • How can we alleviate some of our clients’ anxiety and fear regarding anesthesia?

    This article discusses anesthesia of dental patients, including pitfalls and hurdles that may be encountered in dental procedures. Precautions and safeguards that can help achieve a positive anesthetic outcome are also discussed.

    Choosing an Anesthetic Protocol

    When an anesthetic protocol is being chosen for a dental patient, it is important to consider many factors, including the age, weight, breed, and overall health of the patient. The variety of available premedicants and induction agents allows veterinary anesthetists to tailor the anesthetic protocol to the patient’s specific needs. A preoperative physical examination and workup should be performed, including a minimum of a complete blood count and a serum chemistry profile. Electrocardiography and urinalysis may also be performed to improve the database from which to develop the anesthetic regimen.

    It is important to consider the type of procedure when choosing an anesthetic premedicant. Most, if not all, dental procedures can cause some degree of pain. Procedures that cause mild pain (e.g., periodontal scaling or cleaning), moderate pain (e.g., surgical dental extractions), and severe pain (e.g., mandibulectomy, jaw fracture) should be managed accordingly.2 Including an opioid in the premedication provides sedation and preemptive analgesia, which can be extremely beneficial to patients. Preemptive analgesia is an important part of a multimodal pain management protocol, which is defined as the simultaneous use of two or more analgesic drug classes.3 The multimodal approach entails preemptive, intraoperative, and postoperative administration of analgesics and achieves optimal pain relief by interrupting the pain response at several points along the pain “pathway.” The most beneficial classes of analgesics for dental patients include opiates, α2-agonists, NSAIDs, and local anesthetics.

    Anesthetic Monitoring

    When working in the oral cavity, clinicians must protect the patient’s airway against aspiration of water or debris. After induction, all dental patients should be intubated and the endotracheal tube cuff inflated. Once under general anesthesia, the patient should be provided with an animal-safe heat source (e.g., Bair Hugger Therapy [Arizant Healthcare Inc, Eden Prairie, MN], a warm water circulating blanket), and monitoring sensors should immediately be attached to the patient. Monitoring is important for determining whether the anesthetic plane is appropriate and detecting changes in vital signs.4 This information helps technicians make adjustments necessary to avoid an anesthetic crisis.

    Simple monitors, such as a pulse oximeter, usually monitor only one parameter. While monitoring the oxygen content of arterial blood is important, other parameters should also be monitored. A monitor should preferably perform pulse oximetry, electrocardiography, and capnography as well as measure blood pressure, body temperature, and respiration rate. Parameters should be recorded and assessed every 5 to 10 minutes by trained personnel specifically delegated to monitor the patient throughout the procedure. Relying on alarms alone without human assistance is not recommended.1

    Many complications and sudden death can occur during the recovery period. Therefore, it is essential to continue monitoring the patient once the inhalant has been discontinued. Respiration rate and heart rate should be monitored for several minutes after surgery. Body temperature should be monitored at regular intervals until normothermia is achieved. A heat source should continue to be provided for patients with severe hypothermia (<98°F [<36.7°C]). Patients should be ventilated for several minutes after the anesthetic system is flushed with oxygen to clear the lines of residual inhalant. Patients that have been laterally recumbent for an extended period of time during a dental procedure should be rotated at a regular interval (every 15 minutes) to allow effective ventilation of both lungs until these patients are able to remain sternally recumbent. To avoid aspiration of fluid, the endotracheal tube should be left in place until the swallow reflex becomes consistent. Because of their shortened palate, patients belonging to brachycephalic breeds should not be extubated until they are able to remain sternally recumbent without assistance. In most cases, intravenous fluids can be discontinued once patients are alert and responsive. However, if a patient has compromised renal function, intravenous fluids should be continued for an extended period of time or until the patient is discharged.

    Precautions

    Unlike routine procedures, dental procedures can be lengthy—sometimes 1 to 4 hours. Patient health can become compromised during procedures that are lengthy or invasive or that result in extreme pain, with common complications including hypothermia, hypoxia, hypotension, and changes in anesthetic depth. Providing a heat source is imperative to counteract a reduction in body temperature due to administration of premedications or gas inhalants, the use of water from dental handpieces, and prolonged dental procedures.5 To help stabilize blood pressure, intravenous fluids should be administered throughout dental procedures. Warming the fluids can also help stabilize body temperature.5 For invasive dental procedures, a safe anesthetic depth can be maintained with a lower concentration of the inhalant agent throughout the procedure if an effective pain management protocol is used. This should include preemptive analgesia (premedicants) and intraoperative analgesia such as regional nerve blocks.6 A discussion of regional nerve blocking is beyond the scope of this article; however, I encourage veterinary teams to seek further information and training on this topic to improve their standard of dental care.

    Client Education

    Clients are becoming more aware of the importance of professional dental care for their pets, and anesthesia is an inevitable part of professional dental care. When dental procedures are recommended to clients and pets are admitted for these procedures, the veterinary team should explain the anesthetic plan to clients, including the precautions to ensure an uneventful patient recovery, such as reviewing the results of the preoperative workup and using monitoring equipment. Through effective and diligent anesthetic practices, veterinary teams can greatly increase the success of a positive outcome while minimizing risks to patients. A confident, well-prepared team can help alleviate client fear associated with anesthesia.

    Conclusion

    Although not every adverse reaction to anesthesia can be prevented, it is crucial for veterinary teams to recognize that dental procedures can have different obstacles than some other routine surgical procedures; therefore, specific precautions are required to decrease the chance of anesthetic emergencies during dental procedures. By establishing effective and safe anesthetic protocols tailored to the patient, providing constant monitoring, managing the patient’s pain successfully, and educating clients, the dental team can provide exceptional service to clients and their pets.

    aPeak M. Marketing veterinary dentistry: creating value. Florida Veterinary Medical Association Convention, 2008.

    Downloadable PDF

    Ms. Mills discloses that she has received financial benefits from AFP Imaging and Dental Focus.

    1. Stepaniuk K, Brock N. Anesthesia monitoring in the dental and oral surgery patient. J Vet Dent 2008;25:143-149.

    2. Carpenter R, Manfra S. Anesthesia and analgesia for selected patients and procedures. In: Tranquilli W, Grimm KA, Thurmon JC, eds. Anesthesia and Analgesia. 4th ed. Ames, Iowa: Blackwell; 2007:993-995

    3. Tranquilli W, Grimm KA, Lamont LA. Pain terminology. Pain Management for the Small Animal Practitioner. Jackson, WY: Teton New Media; 2000:2-11.

    4. Paddleford R. Perioperative monitoring. Manual of Small Animal Anesthesia. 2nd ed. Philadelphia, PA: Saunders; 1999:123-146.

    5. Stepaniuk K, Brock N. Hypothermia and thermoregulation during anesthesia for the dental and oral surgery patient. J Vet Dent 2008;25:279-283.

    6. Beckman B. Regional nerve blocks key to delivering quality dental care. DVM September 1, 2007:2-7.

    References »

    NEXT: Equine Essentials: Preparing a Practice for Rattlesnake Envenomation in Horses

    CETEST This course is approved for 1.0 CE credits

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    didyouknow

    Did you know... A horse’s demeanor can be a good indicator of its pain level because painful animals are likely to become withdrawn and dull and may appear irritable. Read More

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