Stefanie Perry, CVT, VTS (Dentistry)
I recently took part in a case that began with a patient’s admission to our urgent care service. The 13-year-old, small breed dog was slowly bleeding from the mouth for about twenty-four hours before presenting to the clinic. This patient had not received any veterinary care since his puppy vaccines and therefore had no medical history. He was too painful to have a conscious oral examination, but it was obvious that periodontal disease played a large part in his clinical signs. We admitted the patient for overnight pain control before general anesthesia and Comprehensive Oral Health Assessment and Treatment (COHAT). Upon sedated oral exam, we found his left mandibular first molar had fallen out and lodged into the alveolus of his left maxillary fourth premolar, which was also significantly mobile. The bleeding was coming from the mandibular canal after the tooth was lost. Intraoral radiographs revealed a pathologic fracture of his left mandible that had already begun to heal, indicating long term deterioration of the bone and chronic pain. The patient had blood and discharge matted in the fur around his mouth, presumably because he was too painful to have his face touched for grooming. He went on to have every tooth extracted and an uneventful recovery.
This case affected me more than most. I struggled to understand how a dog could endure this for so long. He was even slightly overweight, so I knew he was eating and coping with this every day despite the pain. As a dental technician, I see advanced periodontal disease most days. It’s not uncommon and my clinic sees more of the bad cases than many clinics. I’ve become somewhat closed off from thinking about what my patients live with until they get treatment. It’s been easier for my mental health to become jaded in a way. For some reason, this sweet little dog got under my skin, which brings me to why I felt the need to write about it. Our efforts to treat dental disease should start far sooner than when they already have a mandibular fracture. If our efforts to educate save even one patient from this outcome it would be worth it, and by extension, improve our own quality of life.
Dentistry’s Dark Corners
Veterinary staff is inundated with stress in their daily routine. Witnessing patient suffering contributes significantly to the endemic mental health crisis in veterinary medicine. Seeing a pet experience pain from preventable disease, and seeing it repeatedly, wears down veterinary technicians and assistants, causing burnout and compassion fatigue. There are many resources for self-care and how to combat the lasting effects of burnout. Many methods encourage private time away from the clinic and separating our thoughts at the end of the day by being more present at home. In my mind, another way to fight burnout happens on the job, where I can know I did everything I could to prevent disease. Client education can prevent patient suffering when applied consistently while the client is in the clinic. We advise them to avoid hazards like foreign bodies, choose nutritious food, and perform wellness blood testing to detect health problems. A complex topic to talk about with clients is the consequences of neglecting their pets' dental health. We recommend tooth brushing at their annual visits but do not consistently elaborate on what advanced periodontitis can do to their pet's general health. Dentistry carries less value in the minds of pet owners who haven't had experience with it in the past and sometimes garners skepticism because of cost. Veterinary staff fears the financial conversation as well as the moral component of animal neglect.
When we think of animal neglect, many professionals picture emaciated dogs and cats covered in ectoparasites. We imagine wounds left to be taken by infection and limbs lost to amputation as a result. If an animal is hit by a car, the owner is expected to seek immediate care, and if they delay treatment, they are considered cruel because the pet is in obvious pain. But when the patient's pain is not apparent, it is somehow easier to write off their suffering as client ignorance. We can use the term ignorant not as a disparaging term but to mean that they were not aware their pet needed help. For years, I have been able to escape the mental anguish of veterinary dentistry because I consistently tell myself that the client did not know better. I've seen unimaginable chronic pain cases in the oral cavity; fractures, fistulation, bleeding, inflammation, infection. Dental patients often have wind-up pain that is difficult to control under general anesthesia. Similar pathology that would get immediate attention elsewhere on the body is left to advance unchecked inside the mouth.
When an owner finally seeks veterinary care for their pet, inaction is somehow forgiven because they don't have a working knowledge of periodontal disease. Most humans will never experience this torturous pain if they have the resources and capacity to brush their teeth daily. So, we must ask ourselves, how can we avoid watching this happen and endure picking up the pieces of our patients' disease processes? The most valuable tool in our arsenal is client education. The concept may seem trite because the term is used often, but client education is the responsibility and privilege of veterinary professionals. Finding new and inventive ways of achieving this lofty goal is how we grow as professionals and make a difference in the lives of our patients.
Why Do Clients Decline Services?
The scenario is common in both general practice and emergency clinics. Periodontal disease has reached a point that the client detects that something is wrong with their pet. At this point, they seek veterinary care because there is tooth loss, bleeding, sneezing, a draining tract, or other clinical signs that they don't recognize as dental-related issues. At this point in the visit, we present an estimate for treatment and brace ourselves for how the conversation will unfold. For the sake of this hypothetical scenario, the client is declining the dental procedure. We do not know their personal business and history, so there are (theoretically) three different reasons why they would refuse dental care for their pet.
They Don't Believe Us
Even when faced with evidence, some clients will resist that their pet is suffering. They tell us "but they are still eating well" or "they don't seem to be in pain." The most important message regarding their perception of their pet's pain is that animals are hardwired to survive. They will eat because it is instinctually more vital to them than avoiding pain. Swallowing food whole is an acceptable adjustment, so they do not go hungry. This is also reinforced after extractions are performed and they have no teeth left. Chewing is optional and life will go on normally for them.
Denying the evidence presented and insisting on not performing extractions isn't an everyday occurrence, but it has a lasting effect on professionals when it does. Laypeople might picture us quickly extracting teeth and doing so solely to generate profit. They love their pet and can't comprehend why we would want to do this to them. It’s hard for them to accept that by performing extractions, we are relieving pain. Anticipating an emotion response from the pet owner is common when you make the phone call for consent to perform extractions. Thorough knowledge of anatomy and periodontal disease makes the difference in being an advocate for your patient. The path to gain their trust in your expertise is different for each client. Some need to feel the empathy you are experiencing, and others need blunt and direct communication. Skill in recognizing and adapting those needs is developed over time, but intuitively deciding how to get through to a client makes a truly great technician. Communication with each personality type is different and can be learned through continuing education, even if it isn't veterinary related. Human communication, sales, advocacy, and personality seminars will add tools to your client education regimen.
They Don't Understand
Preparing the client at patient admission (before the procedure begins) will make it easier to gain consent during anesthesia. Explain the etiology of periodontal disease and the effect it has on different tissues in the mouth, along with anticipated treatments and how they benefit the patient. Physically show them obvious pathology during the conscious oral exam so they can picture what you are trying to describe over the phone. Client understanding of what we expect to find makes it easier to explain the pathology that we won't see until intraoral radiographs are performed. Hearing this information over the phone creates anxiety for many owners, and their worry about their lack of understanding can cloud their judgement. It's best to be direct and literal in your words. Feel comfortable saying, "the doctor doesn't want to perform surgical extractions on your pet, but we want to do what will relieve your pet's pain and treat infection."
In this scenario, you need to know the criteria for the case to be referred to specialty dentistry. In the event a tooth can be saved via root canal therapy or other advanced procedures, be prepared to refer the patient to a board certified veterinary dental specialist. Ethical treatment of patients includes referring them out of the general practice when necessary. We can never assume when clients will be willing to make a bigger investment in their pet to save teeth. At times, having the opportunity to treat the problem will provide the client some understanding about the needs of their pet and encourage swift action in the future. If, for any reason, they cannot pursue specialty level care, be compassionate and assure them that the care you are providing is still going to make their pet healthier and more comfortable.
They Can't Afford It
It's easy to say that veterinary expenses are part of owning a pet. As professionals, we understand all the different expenses that come with veterinary care. The public, however, gets a pet to enrich their lives and don't have the knowledge to foresee conditions like periodontal disease. When the reality sets in that their pet needs help, the cost estimate comes quickly behind it. This is the cause of anxiety, frustration, and defensiveness that often manifests as abuse to the veterinary staff. It should never be tolerated as it contributes to burnout and influences the staff. Before you turn clients away for this behavior, try to understand the stress they are experiencing. Many clients aren't self aware and don't realize the impression they're making. Others can't manage their emotions when the panic of a big bill sets in.
It is comparable to when a vet tech takes their car to a mechanic. If they don't understand how a car works and why it needs certain repairs, they might get angry when they see an estimate. They need their car to get to work and pick up their child from school so it's not optional. Meanwhile, they feel trapped and stressed about the information being presented to them. Now, add an emotional attachment to the car. If the car had significant sentimental value, they would be even more stressed about the need to spend the money but unable to come up with the funds. This is a recipe for emotional reactions and inappropriate behavior. Before we judge, get frustrated, and take it within us, applying reason to their reaction could keep it from having a lasting effect on our mental health.
Strategies For Good Outcomes
Most of our clients are compliant with our treatment plans. Even if they struggle to understand or have a budget to worry about, they are part of a cooperative effort with us to care for their pet. On the occasion a client needs special attention, it's important to have a collection of aids to make the situation easier. There are clients who need numbers or written plans and others who need visual aids to process your messages. Beside the typical client education materials, you should arm yourself with many tools to use on-demand if the need arises.
Cost Breakdown
Using your clinic's prices, write up a comparison showing the cost of annual preventive dental care versus the cost of repeated surgical intervention. Practices should make preventive care affordable and not cost-prohibitive while not devaluing the service provided so this analysis can work. By consistently being present for a Comprehensive Oral Health Assessment and Treatment (COHAT), owners can save themselves thousands of dollars in periodontal therapy. Before severe periodontal disease sets in, a COHAT is quicker, which calls for fewer medications and less general anesthesia time. There is also a savings on surgical supplies and professional services such as extractions and oral surgery. If cost analysis showing all these considerations makes it more logical for them, it can be presented that way for the right client.
Visual Aids
Before and after photos are so rewarding for staff members, and we should share that with pet owners. A visual representation of the investment they've made in their pet will help bring value to the price of your services. For patients with advanced periodontal disease, take a photo after scaling has been performed to help illustrate the meaning of gingival recession, tooth mobility, furcation exposure and other pathology that is often obscured by calculus accumulation. Use laymen's terms for pathology but allow the client to see the reality of what's going on inside their pet's mouth. We can send images via email during a procedure and leveraging technology to gain client consent for surgery could make the process faster. Putting together all the photos and radiographs in a template at the end of the day provides visual aids for discharge and added reinforcement of your educational goals.
Animal Advocacy
There are many ways to fight burnout, but repeated exposure to severe cases makes it difficult to tell the difference between abuse, neglect, and lack of understanding. The line between abuse and benign neglect is very slim when you see advanced periodontal disease that results in jaw fracture or orofacial fistulae. It can feel impossible to understand how someone can allow their pet to suffer that way. We must always attempt to set aside our feelings and be the professional your patient needs to heal. To combat burnout, make client education a habit that encourages preventive care. Your team can be a champion of dental education that makes a difference to your patients’ health. The effort saves your patients from suffering chronic dental pain and preserves your passion for animal advocacy.