DONATE NOW

Delving into Dental Radiography: Equipping your Practice for Radiographic Success

erin-dentistryBy Erin Abrahams, DVM
Angell Dentistry Service
617-522-7282
www.angell.org/dentistry

Full-mouth, intra-oral (FMIO) radiography has become the standard of care for all patients undergoing a dental procedure under general anesthesia. Tables 1 & 2 summarize the findings of one study conducted over a decade ago, demonstrating why radiography is an invaluable tool for every veterinary practitioner who provides dentistry services1,2.

Table 1. Radiographs of Teeth WITHOUT Clinical Lesions:

Dogs Cats
Incidental Findings 41.7% 4.8%
Clinically Important Findings 27.8% 41.7%
No Clinical Value 30.5% 53.6%

Table 2: Radiographs of Teeth WITH Clinical Findings

Dogs Cats
Confirmed Findings 24.3% 13.9%
Additional Findings 50% 53.9%
Clinically Important Findings 22.6% 32.2%
No Clinical Value 3.1% 0%

Based on the above findings, dental radiographs revealed clinically important findings in over half of canine and feline patients combined, either with or without clinical disease identified upon examination. The clinical indications for dental radiography have been well-described elsewhere and are outlined below3, 4.  The list goes on, however the number of veterinary practices that either do not have dental radiography available, or are not using it fully, is alarming.

Indications for Dental Radiographs

  • Feline Patients: All cats have resorptive lesions until proven otherwise
  • Fractured Teeth
  • Worn Teeth
  • Discolored Teeth
  • Missing Teeth
  • Rotated/Crowded Teeth
  • Gingival Hyperplasia
  • Facial Swelling
  • Oral Masses
  • Periodontal Pockets
  • Perulis (Draining Tract)
  • Pre-extraction: Root anomalies, mandibular cortex integrity (FIGURE 2)
  • Post-extraction: Ensure all root structure is removed
  • Establish baseline of normal dentition and/or incidental findings to be followed over time
  • Maxillofacial Trauma
  • Nasal Discharge
  • Oral Pain
  • Drooling
  • Halitosis
  • Detailed and Complete Medical Record Keeping: Avoid Litigation!!

So Why the Disparity?

Lack of formal education and training is the main challenge for many general practitioners, especially those who have been in practice for a decade or longer. Most veterinary schools still do not provide adequate training and education in dentistry topics and fail to provide appropriate, if any, hands-on experience. Unless continuing education and wet labs are attended, veterinarians may not be using the appropriate techniques to minimize tissue trauma and may lack familiarity with normal anatomy which can significantly improve confidence and efficiency when navigating the 30 teeth in felines and 42 teeth in canines.

In order to close the gap, practices must dedicate time and resources to invest in appropriate equipment, continuing education, staff education, and client education. The most essential tool around which to build a successful dental program is undoubtedly, dental radiography.

If your practice is performing FMIO radiographs for all patients when indicated (first dental procedure under general anesthesia and at reasonable intervals for annual follow-up procedures), then hats off to you! If not, then this article will provide some tips and recommendations to get your practice headed in the right direction.

In order to close the gap, practices must dedicate time and resources to invest in appropriate equipment, continuing education, staff education, and client education. The most essential tool around which to build a successful dental program is undoubtedly, dental radiography.

If your practice is performing FMIO radiographs for all patients when indicated (first dental procedure under general anesthesia and at reasonable intervals for annual follow-up procedures), then hats off to you! If not, then this article will provide some tips and recommendations to get your practice headed in the right direction.

This radiograph reveals the thin ventral cortex and risk of iatrogenic fracture during extraction. Also note the dilaceration of the mesial root, an additional important finding when planning extraction to avoid root fracture.

This radiograph reveals the thin ventral cortex and risk of iatrogenic fracture during extraction. Also note the dilaceration of the mesial root, an additional important finding when planning extraction to avoid root fracture.

The Team

Before you make any large purchases or upgrades, find your clinic’s dentistry guru. If you don’t currently have one, either place an ad or foster the interest in a deserving employee through continuing education. You need at least one member of your team to advocate for and promote your dental program. This can be a veterinarian, a technician, a practice manager, or the owner. At least one key team member who will put the time and energy into continuing education, learning the equipment, and who will hold the rest of the team accountable for making sure your dental radiography equipment is fully utilized.

The Equipment

For the sake of this discussion, we will cover digital dental radiograph units. If standard x-ray film is available to you, it is a better alternative to not taking dental radiographs. However, in the interest of time, efficiency, and return on investment, the best equipment will be either a DR (direct radiography) or CR (computed radiography) system.

DR Considerations5:

  • Almost instantaneous image generation: Within seconds you will be able to view the image delivered directly from the sensor to your computer screen.
  • Only available in Size 1 and 2 plates: What you make up for in time, x-ray generation, and image retrieval, you lack in sensor size variability. However, with the speed of image acquisition, the trade-off is minimal. You can capture all the views you need with a size 2 plate, even in the largest canine patient.
  • Thick, unyielding sensor: This won’t be a problem for most patients, but may pose a challenge to obtain the parallel mandibular molar/premolar views in felines and small canines.
  • High cost of sensor replacement: These sensors will come with a replacement plan in the event of sensor damage, however it is expensive. Fortunately these sensors are extremely hardy and the risk of damage is minimal and should not be a deterrent.

CR Considerations5:

  • Slightly longer image generation: Image processing requires the intermediate step of feeding the photostimulable storage phosphor (PSP) plate through the processor. However, image generation is still accomplished in seconds, and multiple plates can be loaded simultaneously.
  • Wide variety of plate sizes, ranging from 0-4: Despite slightly longer development time, you can capture more anatomy on a larger plate that will reduce your number of exposures, again resulting in a minimal trade-off between CR and DR when considering the time factor.
  • Thin, flexible film: The PSP plates are easy to work with and manipulate in order to obtain your image. The variety of sizes also contributes to greater adaptability and novel uses of the plates i.e. using a size 4 plate to obtain bilateral TMJ anatomy in a feline patient.
  • High consumables cost: Each PSP plate requires plastic sleeve covers in order to protect the plate from fingerprints, moisture, and scratches during exposure. Additionally, PSP plates can become damaged and worn after a high-volume of exposures, and will require replacement over the life of the equipment. Also consider the number of each size plate that you may want to have available for each procedure. More plates will allow for faster turn-over and image acquisition.

Time is Money

The greatest hurdle you must overcome is the ability to optimize digital dental radiography and what it can accomplish. For some practices, the process of obtaining full-mouth radiographs may take 30-60 minutes to develop. This can be influenced by type of equipment (traditional film vs. digital radiography) and operator efficiency, both variables that are within your control. With a well-trained and confident staff, FMIO radiographs should be completed in 10 minutes or less, depending on the size of the patient. YES, IT IS POSSIBLE!

To achieve this goal requires patience, dedication, and time. You must make the up-front investment through education and practice, practice, practice! Purchase a skull or cadaver (cadavers are a bit easier to work with for placement of the sensor or film plate due to the soft tissue support structures, and can also be used to practice extraction technique before working in live patients) to allow your staff (doctors and technicians) to practice their technique until they can comfortably obtain FMIO radiographs in 10 minutes. Your practice will very quickly recoup the initial investment of a day of training once you can capture a full-mouth series in every patient, every time. And with each additional case, your team will continue to get better!

The Value is in the Pathology

A common frustration that often dissuades practices from using dental radiographs is determining how to charge appropriately, and the disappointment of clients who ultimately decline this service. So how should your practice charge? The simple answer is – DON’T! Dental radiographs are an integral part of your diagnostic and treatment plan, and should be part of your baseline work-up for all patients.

Whether you list them as a line item or not, the client should never have the choice to decline this invaluable diagnostic tool. To achieve this, work the cost of radiographs into the overall price of your comprehensive oral health assessment and treatment (COHAT) plan so there is one less thing for clients to question or decline. For example, set your base price of the COHAT at $350 to include the first hour of anesthesia, probing, charting, FMIO radiographs, scaling and polishing. For a healthy patient with no oral pathology, this would be the total price of the procedure, which should take an hour or less to complete, depending on the size of the patient. Any additional pathology that you discover upon charting and through radiography will be charged in addition to the base fee (either based on the specific treatments completed, or based on time to complete the procedure). The radiographs will pay for themselves once you identify, document, and treat the disease below the gum line, and your clients will appreciate your ability to provide the best care for their pet.

I Found the Pathology, Now What?

Perhaps a final hurdle that practitioners must overcome when reaching for dental radiographs is interpretation and treatment planning. There are a multitude of continuing education opportunities in radiographic interpretation and extraction techniques that can equip practitioners with the confidence to address the majority of dental disease cases in your practice, and the knowledge to refer when appropriate.

Investing in dental radiography will elevate your dentistry practice to provide exceptional patient care and ensure that your client’s money is well spent. With each case, your efficiency and proficiency will improve, resulting in a successful dental program and return on investment.

Tips for Success

  1. Review pertinent radiographic findings with your clients. Show them radiographs from a normal patient and compare to their pet’s x-rays. Clients will immediately appreciate the value of the service and thank you for making their pet feel better.
  2. Invest in a skull model as well as a rubber skull with removable teeth. Being able to remove the teeth and visualize the root structure in relation to the skull will help with radiographic positioning, as well as surgical extraction technique.
  3. Join the American Veterinary Dental Society at www.avds-online.org. Membership includes the quarterly Journal of Veterinary Dentistry, the monthly AVDS newsletter with a “Case of the Month,” access to learning materials through the AVDS online store, CE and networking opportunities, and discounted registration to the Veterinary Dental Forum.

For more information regarding digital dental radiography or CE opportunities, please contact Dr. Erin Abrahams at dentistry@angell.org or (617) 522-7282.

 

References

  1. Verstraete FJ, Kass, PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am JVet Res 1998;59:686-691.
  2. Verstraete FJ, Kass, PH, Terpak CH. Diagnostic value of full-mouth radiography in cats. Am JVet Res 1998;59:692-695.
  3. Hale F. Why should you do whole-mouth intra-oral dental radiographs? Can Vet J 2013;54:889-890.
  4. Bannon KM. Clinical canine dental radiography. Vet Clin Small Anim 2013;43:507-532.
  5. Coffman CR, Brigden, GM. Oral and dental imaging equipment and techniques for small animal.
  6. Vet Clin Small Anim 2013;43:489-506.
  <- Simpli.fi global tag ->