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By Tony M. Woodward, DVM, AVDC
In my experience, there are several areas that must be addressed in order to achieve the potential for delivery of dental care in a general practice. These include defining your dental message, education of staff, consistent delivery of your educational message to clients, “low impact” anesthesia, the ability to proactively diagnose dental disease, the doctor’s ability to perform some basic procedures, and a willingness to charge appropriately for your professional time. We will examine each of these areas in turn.
Define your message
Each practice has to decide the level of dental care they will espouse as part of their practice mission. In many cases this has already been decided on, by default, as a minimal level of recommended care. By de-emphasizing the need for dental care, a practice unconsciously sends the message to clients that dental care is not important for animals. You will need to first decide the level of care your practice will recommend. All the other steps in marketing dentistry flow from this first step.
Staff education
Good dental care requires that the entire staff, from receptionist to technician and kennel help, have an awareness of how dental disease effects pets and how to recognize potential problems. Once the staff understands dental disease, they will be your teammates in getting the needed care delivered to the clients. There are many resources you can tap to help educate your staff. Numerous dental CE opportunities exist around the U.S. Many suppliers and drug companies are willing to come into your practice, present seminars about dental disease and provide lunch for your staff. The important thing is that the doctor let the staff know that dental disease is a problem that the entire team needs to work on. It is of little benefit to train a technician or doctor, if the receptionist tells Mrs. Smith that “Sparky” does not really need to have his teeth fixed.
Delivering the message to clients
Clients are very interested in learning about how to take better care of their pets. Anything that can decrease pain and improve their pet’s quality of life strikes a responsive chord in many pet owners. For any new idea to be well received by your clients, they must hear a consistent message from your entire organization. Ideally, a client reads about dental disease in your newsletter, saw something in a magazine recently, hears it in your “message on hold” recording, has it mentioned by the receptionist when booking the appointment, sees some literature while in your waiting room, and has the technician comment on possible problems in the exam room. When the doctor finally confirms that their pet indeed appears to have a dental problem and would benefit from care, the owner is only too happy to pursue treatment. This approach has been integrated into many areas of small animal practice, to market and sell many services whose need is far below that of dental disease in pets. A few examples are listed in the chart below. Please keep in mind that these are my personal estimates for incidence of these diseases in the area of Colorado I practiced in for 19 years. Disease incidence in other parts of Colorado and in your own practice area will vary, but I think this illustrates a point.
| EXAMPLES OF SERVICES MARKETED IN VETERINARY MEDICINE | |
| Disease | Guestimated incidence in overall Colorado dog and cat populations |
| GI Parasites | 5% or lower |
| Heartworm Disease | < 1% |
| Canine and Feline Distemper | < 1% |
| Ticks | < 1% |
| Fleas | 1-3 % |
| Dental Disease | 50% |
My purpose in pointing this out is not to suggest that services targeting the above should be reduced or eliminated, but rather to make two points. First, the educational efforts of the veterinary community are strongly influenced by the marketing plans of the drug/vaccine companies. These companies know how to get clients to agree to make a medical purchase. They provide you and your staff with well-produced educational literature, and help you deliver this message to your clients. This is not a criticism, but rather an observation of an effective marketing effort. We should learn from the success of these companies. Second, we have been relatively successful selling services that target relatively infrequent medical conditions. How much easier would it be to educate the public about a problem that occurs much more frequently? Imagine the relative ease in selling dental services whose incidence is 50%, that is naturally recurring, that is treatable but not curable, and causes pain! In addition, good dental care can never be a commodity sold on the Internet or at a feed store. Your clients will keep coming back to you for dental care, as they do themselves with their own dentist. If you could invent a new “perfect disease” to market, you would be hard pressed to do better than dental disease.
One thing to emphasize with owners is that patients rarely show obvious signs of dental pain. Dental pain tends to come on slowly, so owners do not notice any behavioral changes. A dog or cat with severe dental pain will keep eating until they are almost ready to expire, although they might be swallowing their food whole. Usually, the only sign that occurs is that the patient “acts older”. This is not usually apparent until after treatment, when the owner notices a dramatic difference. You might point out to the owner that, in the wild, a Canid or Felid that shows any sign of weakness loses social standing, or may be a meal for another predator. It is not in their best interests to show any type of weakness.
There are many tools you can use to help educate clients about dental problems in their pets. Educational models and brochures are available from many sources, and vendors will frequently supply free materials for educating staff and clients. Using digital and instant cameras allows you to show the owner what their pet’s mouth looked like before and after treatment, and gives the owner something to take home to show other family members. Clients love “seeing” a problem. Digital pictures can be easily inserted into a prepared template, customized to your clinic. When printed out and given to the client, the results have been very rewarding for the author. Taking the time to show clients the dental radiographs from their pet is very beneficial. If you show clients pictures and radiographs from their own pet, they will brag to their friends about their pet’s “state of the art care”. You can quickly become an authority in your community, if you take the time to educate your clientele.
“Low Impact” Anesthesia
One of the major client concerns, and rightfully so, is anesthetic safety. This is the main reason that “non-anesthetized” dental cleanings have gained a foothold despite their pathetic level of care. Clients do not want their pet acting groggy for a day after a dental cleaning. When they see that happen, they are very reluctant to schedule the next dental procedure. Your goal should be to have your patients looking happy and ready to go home one hour following a three hour anesthetic episode. There are a few things that have noticeably helped the quality of my anesthesia. These include:
- Pre-surgical chemistry screening if not done in the last 6 months or if any chronic condition effecting anesthesia is known to exist.
- IV catheters and fluids for all anesthetized patients. For a complete review, see the JAVMA review article, Perioperative Fluid Therapy, in the Oct 15, 2002 issue, page 1112.
- Anesthetic monitoring including blood pressure monitoring and pulse oximetry.
- Aggressively treating low blood pressure when encountered.
- Warm water blankets or equivalent.
- Using drugs that are eliminated quickly or can be reversed, such as Propofol, narcotics, Alpha-2 Agonists, and Isoflourane/Sevoflurane.
- Avoiding drugs such as Ketamine and Barbiturates in dental procedures. These drugs are safe to use, but can be associated with a prolonged recovery time.
- Proactive pain control measures such as regional nerve blocks, “splash blocks” in sutured extraction sites, and appropriate pain medication post-operatively and for at-home use.
If your patients go home one hour after anesthesia, wagging their tails, your clients will brag about your hospital, will refer their friends, and will be much more likely to schedule a procedure in the future. Complaints about “anesthetic hangovers” are the number one complaint I hear from dissatisfied owners seeking better care for their pets. Another excellent review article is Myths and Misconceptions in Small Animal Anesthesia, JAVMA, Vol. 223, No. 10, November 15, 2003, pp 1426-1431.
The ability to correctly diagnose dental problems
The only way you will ever be able to correctly diagnose dental pathology is by using a standard 12-step cleaning procedure in every patient, followed by a detailed exam, with charting, by the doctor. All areas of pathology need to be measured and noted in the record. All areas of suspected pathology (discolored teeth, periodontal pockets, fractured teeth, overgrown gingival tissue, suspected oral tumors, areas of bone loss, etc.) require dental radiographs to show the true extent of disease and to guide treatment decisions. Dental radiographs are the single most underused diagnostic test in small animal medicine. Finding loose teeth usually means that a problem is present that required treatment years sooner.
The doctor’s ability to deliver five basic dental procedures
There are a few dental procedures, well within the grasp of most practitioners, accounting for over 90% of all required dental treatment. You do not need to know how to perform more advanced dental procedures, such as root canal therapy, to allow you to deliver most dental care. These basic techniques include:
- A quality 12 step cleaning procedure.
- Dental radiographs. It is simply not possible to provide good quality dental care without dental radiographs.
- Surgical extractions. Using flaps allows improved exposure for sectioning teeth, easier extraction of root fragments, smoothing the bone in the extraction site, and closure of the surgical site. In my experience, surgical extractions allow faster healing and give you the opportunity to provide superior post-operative analgesia by utilizing “splash blocks” of local anesthetic agents.
- Basic treatment of periodontal pockets. Closed root planing, gingivectomy, and the use of Doxirobe gel are adequate treatment for many early periodontal problems.
- Smoothing fractured teeth and applying light cured dentinal sealants to exposed live dentin will decrease sensitivity and help prevent future pulp infection.
These techniques are not particularly difficult, but do require some formal training to master. Practice on cadavers will quickly built confidence.
Willingness to charge for your time and skills
Veterinarians are the most wonderful group of professionals on the face of the earth. In order to care for our patients, we will sacrifice almost anything, including our own financial stability and that of our family and employees. This is a difficult area for us to address because most of us went into veterinary medicine because we love our work and our patients, not because of money. Here are a few ideas to help you get over this “hump”.
- Let clients and your staff know ahead of time that a “dental” does not include any extra anesthesia, dental X-rays, or surgery time involved with additional needed care such as extractions or periodontal treatment. A human dental prophylaxis does not include free treatment for a cavity found at the time of the cleaning. Do you include a free lumpectomy with each spay?
- Dental procedures should be charged like any other elective surgery such as an abdominal exploratory, fracture repair, or lumpectomy. Your costs are the same. Figure out a fair return for your time per minute with anesthesia, a trained assistant, surgical supplies, and quality anesthetic monitoring. Apply this charge per minute to how long a dental procedure is going to take.
- Have an assistant present estimates to clients. Once I started doing this, I was amazed at how much more relaxed I was, and how I could concentrate on providing good medicine without worrying about financial issues. After giving the client a detailed explanation of your treatment recommendations, let them know you would like them to have a detailed explanation of what the costs will be. Then let an assistant present the estimate, while you go on to do things that you do best, like diagnosing, prescribing, and doing surgery.
Conclusions
The average practice can and should be grossing 15-20% of revenues in the dental department. By educating the staff and clients, you will find yourself delivering needed care. Owners will notice the difference in how their pets act, which will help you achieve higher levels of client satisfaction and loyalty.