Perioperative considerations in dentistry and oral surgery

Alexander M. Reiter; Ana Castejon-Gonzalez

doi:10.22233/9781905319602.13

British Small Animal Veterinary Association , 338 (2018); https://doi.org/10.22233/9781905319602.13

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Perioperative considerations in dentistry and oral surgery

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Authors: Alexander M. Reiter and Ana Castejon-Gonzalez
From: BSAVA Manual of Canine and Feline Dentistry and Oral Surgery
Item: Chapter 13, pp 338 - 370
DOI: 10.22233/9781905319602.13
Copyright: © 2018 British Small Animal Veterinary Association
Publication Date: September 2018

Abstract

This chapter provides information on topics not or only briefly covered in previous chapters, including select intra- and postoperative considerations, use of antibiotics, the role of technicians/nurses and dental hygienists, safety in the workplace, equipment maintenance, considerations about dental scaling without anaesthesia, home oral hygiene, and communication with clients and other professionals.

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Figures

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13.1

(a) Spring-loaded mouth gag advertised for use in cats and small dogs above needle caps cut to lengths of 20 mm and 30 mm, and a 42 mm needle cap. (b) Commercially available mouth props whose lengths can further be adjusted by unscrewing one part from another. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.1 (a) Spring-loaded mouth gag advertised for use in cats and small dogs above needle caps cut to lengths of 20 mm and 30 mm, and a 42 mm needle cap. (b) Commercially available mouth props whose lengths can further be adjusted by unscrewing one part from another. (© Dr Alexander M. Reiter)

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13.2

(a, b) When using a 42 mm needle cap for mouth opening, the lips and cheeks become very tight. This makes it difficult to fully access the caudal teeth and their supporting tissues. (c, d) When using a needle cap cut to a length of 30 mm for mouth opening, the lips and cheeks can be retracted more easily. (e, f) When using a needle cap cut to a length of 20 mm for mouth opening, the lips and cheeks can be readily retracted. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.2 (a, b) When using a 42 mm needle cap for mouth opening, the lips and cheeks become very tight. This makes it difficult to fully access the caudal teeth and their supporting tissues. (c, d) When using a needle cap cut to a length of 30 mm for mouth opening, the lips and cheeks can be retracted more easily. (e, f) When using a needle cap cut to a length of 20 mm for mouth opening, the lips and cheeks can be readily retracted. (© Dr Alexander M. Reiter)

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13.3

Pharyngeal packing for cats and small dogs using two small gauze sponges. (a) One sponge is opened. (b) The other sponge is wrapped to a ball and placed into the centre of the opened sponge. (c, d) The opened sponge is closed, and its ends are twisted. The bulkier part is placed into the pharynx, while the twisted, cord-like end is left to hang out from the side of the mouth. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.3 Pharyngeal packing for cats and small dogs using two small gauze sponges. (a) One sponge is opened. (b) The other sponge is wrapped to a ball and placed into the centre of the opened sponge. (c, d) The opened sponge is closed, and its ends are twisted. The bulkier part is placed into the pharynx, while the twisted, cord-like end is left to hang out from the side of the mouth. (© Dr Alexander M. Reiter)

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13.4

Polyvinyl alcohol (PVA) rings with loop string prior to hydration with water (left). Once it is hydrated with water, the expanding, soft, flexible and sponge-like ring is slid over the middle section of a cuffed endotracheal tube (right); after intubation, a finger is used to advance it along the tube into the pharynx. The disadvantage of these devices is that they cannot be replaced during a procedure when they become soaked with fluids. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.4 Polyvinyl alcohol (PVA) rings with loop string prior to hydration with water (left). Once it is hydrated with water, the expanding, soft, flexible and sponge-like ring is slid over the middle section of a cuffed endotracheal tube (right); after intubation, a finger is used to advance it along the tube into the pharynx. The disadvantage of these devices is that they cannot be replaced during a procedure when they become soaked with fluids. (© Dr Alexander M. Reiter)

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13.5

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13.5 Application of lubricant ophthalmic ointment to the cornea. (© Dr Alexander M. Reiter)

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13.6

To allow access to the cleft palate in this puppy with limited mouth opening, the mandibular symphysis and intermandibular tissues were incised, the sublingual mucosa detached from the laterally deviated mandibles, and the tongue pulled caudoventrally, causing episodes of bradycardia and asystole secondary to trigeminocardiac reflex. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.6 To allow access to the cleft palate in this puppy with limited mouth opening, the mandibular symphysis and intermandibular tissues were incised, the sublingual mucosa detached from the laterally deviated mandibles, and the tongue pulled caudoventrally, causing episodes of bradycardia and asystole secondary to trigeminocardiac reflex. (© Dr Alexander M. Reiter)

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13.7

(a) A Golden Retriever dog with a malignant peripheral nerve sheath tumour had a (b) right total mandibulectomy and left partial mandibulectomy performed. Acute bleeding occurred on the morning of discharge (4 days after surgery); (c) the person walking the dog tried to control bleeding with a laboratory coat. (d) The dog was intubated, and repeated attempts at clamping bleeding vessels were unsuccessful. (e)(i–iii) A pressure bandage was applied after thoroughly rinsing the wound. (f, g) The wound was debrided daily, followed by application of new pressure bandages; the wound was closed 8 days after the initial surgery. (h) The dog returned 17 days after the initial surgery for suture removal. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.7 (a) A Golden Retriever dog with a malignant peripheral nerve sheath tumour had a (b) right total mandibulectomy and left partial mandibulectomy performed. Acute bleeding occurred on the morning of discharge (4 days after surgery); (c) the person walking the dog tried to control bleeding with a laboratory coat. (d) The dog was intubated, and repeated attempts at clamping bleeding vessels were unsuccessful. (e)(i–iii) A pressure bandage was applied after thoroughly rinsing the wound. (f, g) The wound was debrided daily, followed by application of new pressure bandages; the wound was closed 8 days after the initial surgery. (h) The dog returned 17 days after the initial surgery for suture removal. (© Dr Alexander M. Reiter)

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13.8

(a) A 2.5-month-old puppy presented with an open fracture (*) of the right caudal mandible. (b) An extraoral radiograph was obtained, the fracture site was debrided, rinsed and sutured closed, and (c) a tape muzzle was placed. (d) The puppy returned 1 month later; there was good occlusion, the oral wound had healed (e) clinically and (f) radiographically (*), and the tape muzzle was removed. 409 = permanent right mandibular first molar tooth; 410 = resorbing permanent right mandibular second molar tooth; 507 and 508 = deciduous right maxillary third and fourth premolar teeth; BT = bulla tympanica; MB = mandibular body; TMJ = temporomandibular joint; ZA = zygomatic arch. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.8 (a) A 2.5-month-old puppy presented with an open fracture (*) of the right caudal mandible. (b) An extraoral radiograph was obtained, the fracture site was debrided, rinsed and sutured closed, and (c) a tape muzzle was placed. (d) The puppy returned 1 month later; there was good occlusion, the oral wound had healed (e) clinically and (f) radiographically (*), and the tape muzzle was removed. 409 = permanent right mandibular first molar tooth; 410 = resorbing permanent right mandibular second molar tooth; 507 and 508 = deciduous right maxillary third and fourth premolar teeth; BT = bulla tympanica; MB = mandibular body; TMJ = temporomandibular joint; ZA = zygomatic arch. (© Dr Alexander M. Reiter)

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13.9

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13.9 Various sizes of nylon muzzles. (© Dr Alexander M. Reiter)

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13.10

(a–c) The basic design of a tape muzzle consists of a loop encircling the upper and lower jaws connected to a loop running ventral to the ears and around the neck; the second loop may be tied like shoelaces. (d–f) A third loop running over the forehead and connecting the first and second loops often helps to effectively keep the muzzle in position in cats and short-nosed dogs. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.10 (a–c) The basic design of a tape muzzle consists of a loop encircling the upper and lower jaws connected to a loop running ventral to the ears and around the neck; the second loop may be tied like shoelaces. (d–f) A third loop running over the forehead and connecting the first and second loops often helps to effectively keep the muzzle in position in cats and short-nosed dogs. (© Dr Alexander M. Reiter)

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13.11

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13.11 (a) Soiled tape muzzles should (b) be replaced daily or at least every 2–3 days. (© Dr Alexander M. Reiter)

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13.12

Equipment for oesophagostomy feeding tube placement. (a) Basic supplies include a choice of red rubber catheter or silicone feeding tube, scalpel blades, surgical gloves, large curved forceps, needle holder, nylon suture material, and a ‘Christmas tree’ adaptor with injection cap (for use with a red rubber catheter). (b) Neck wraps can be made by using non-adherent gauze pad, antibacterial ointment, cast padding, and a light layer of flexible self-adherent bandage material. (c–g) Washable fabric neck wraps of all sizes (e.g. Kitty Kollar®) are commercially available for cats and dogs. P = proximal aspect of the feeding tube. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.12 Equipment for oesophagostomy feeding tube placement. (a) Basic supplies include a choice of red rubber catheter or silicone feeding tube, scalpel blades, surgical gloves, large curved forceps, needle holder, nylon suture material, and a ‘Christmas tree’ adaptor with injection cap (for use with a red rubber catheter). (b) Neck wraps can be made by using non-adherent gauze pad, antibacterial ointment, cast padding, and a light layer of flexible self-adherent bandage material. (c–g) Washable fabric neck wraps of all sizes (e.g. Kitty Kollar®) are commercially available for cats and dogs. P = proximal aspect of the feeding tube. (© Dr Alexander M. Reiter)

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13.13

(a, b) Large, curved forceps are inserted into the oesophagus with the tips pushed laterally (dorsal to the jugular vein and ventral to the wing of the atlas); a full-thickness incision is made with a scalpel blade directly over the tips of the forceps through the aseptically prepared skin (circled), subcutaneous tissues, and into the oesophagus. (c, d) Measurement of the tube from the incision site to the eighth intercostal space (white tape on lateral chest); the tube is marked with a permanent marker (arrowed) before its distal end is grasped with the jaws of the forceps. (e, f) The distal tube end is pulled orally and out through the mouth and redirected back into the mouth. (g, h) The distal tube end is pushed down into the oesophagus with the operator’s fingers, at which point the proximal tube end flips from pointing caudally to pointing rostrally. Proper tube placement is confirmed either (i, j) via endoscopy or (k) a lateral thoracic radiograph. D = distal end of the feeding tube; P = proximal end of the feeding tube. (l–q) The tube is secured to the skin with nylon sutures in a purse-string pattern around the stoma and a Chinese finger-trap pattern along its proximal end, followed by placement of a neck wrap (see Figure 13.12 ). P = proximal end of the feeding tube. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.13 (a, b) Large, curved forceps are inserted into the oesophagus with the tips pushed laterally (dorsal to the jugular vein and ventral to the wing of the atlas); a full-thickness incision is made with a scalpel blade directly over the tips of the forceps through the aseptically prepared skin (circled), subcutaneous tissues, and into the oesophagus. (c, d) Measurement of the tube from the incision site to the eighth intercostal space (white tape on lateral chest); the tube is marked with a permanent marker (arrowed) before its distal end is grasped with the jaws of the forceps. (e, f) The distal tube end is pulled orally and out through the mouth and redirected back into the mouth. (g, h) The distal tube end is pushed down into the oesophagus with the operator’s fingers, at which point the proximal tube end flips from pointing caudally to pointing rostrally. Proper tube placement is confirmed either (i, j) via endoscopy or (k) a lateral thoracic radiograph. D = distal end of the feeding tube; P = proximal end of the feeding tube. (l–q) The tube is secured to the skin with nylon sutures in a purse-string pattern around the stoma and a Chinese finger-trap pattern along its proximal end, followed by placement of a neck wrap (see Figure 13.12 ). P = proximal end of the feeding tube. (© Dr Alexander M. Reiter)

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13.14

(a) A cat presented with systemic inflammatory response following poorly performed tooth extractions; the orofacial tissues were severely swollen. (b, c) Maxillary and (d, e) mandibular oral photographs and dental radiographs revealed numerous retained root remnants, gingivitis and purulent discharge from open alveoli. The cat returned (f, g) 3 and (h, i) 24 weeks following removal of root remnants and suturing of extraction sites, showing complete resolution of orofacial swelling and healing of extraction sites. (© Dr Alexander M. Reiter, reproduced from Reiter et al. (2004) , Journal of Veterinary Dentistry, with permission) © 2018 British Small Animal Veterinary Association

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13.14 (a) A cat presented with systemic inflammatory response following poorly performed tooth extractions; the orofacial tissues were severely swollen. (b, c) Maxillary and (d, e) mandibular oral photographs and dental radiographs revealed numerous retained root remnants, gingivitis and purulent discharge from open alveoli. The cat returned (f, g) 3 and (h, i) 24 weeks following removal of root remnants and suturing of extraction sites, showing complete resolution of orofacial swelling and healing of extraction sites. (© Dr Alexander M. Reiter, reproduced from Reiter et al. (2004) , Journal of Veterinary Dentistry, with permission)

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13.16

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13.16 (a) Goggles and surgical mask. (b) Disposable face shield. (c) Respirator mask. (© Dr Alexander M. Reiter)

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13.17

Instrument-mounted and hand-held shields are used for retinal protection during light-curing of a composite restoration at the right maxillary canine tooth of a dog. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.17 Instrument-mounted and hand-held shields are used for retinal protection during light-curing of a composite restoration at the right maxillary canine tooth of a dog. (© Dr Alexander M. Reiter)

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13.18

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13.18 Powder-free nitrile gloves. (© Dr Alexander M. Reiter)

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13.19

(a) Human spinal column in a saddle-sitting position, showing maintenance of normal spinal curvature even in a reach-forward activity. (b) Nearly perfect positioning of an operator. (a, Reproduced with permission from Bambach Saddle Seat (Europe) Ltd.; b, © Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.19 (a) Human spinal column in a saddle-sitting position, showing maintenance of normal spinal curvature even in a reach-forward activity. (b) Nearly perfect positioning of an operator. (a, Reproduced with permission from Bambach Saddle Seat (Europe) Ltd.; b, © Dr Alexander M. Reiter)

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13.20

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13.20 (a) Front and (b) side view of a saddle chair. (© Dr Alexander M. Reiter)

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13.21

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13.21 Various instrument handle shapes; lightweight (hollow) and thicker handles with an appropriate pattern are preferred. (© Dr Alexander M. Reiter)

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13.22

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13.22 The cord of an ultrasonic handpiece can be (a) secured with the little finger or (b) draped around the forearm. (© Dr Margherita Gracis)

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13.23

(a) Magnification terminology. (b) Angle terminology. (c) Declination angle that is (i) too small, (ii) too large, and (iii) optimal. (d) Nearly perfect positioning of an operator in relation to the declination angle. (Reproduced with permission from DP Medical Systems, Ltd) (b, c, Reproduced with permission from DP Medical Systems, Ltd.; d, © Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.23 (a) Magnification terminology. (b) Angle terminology. (c) Declination angle that is (i) too small, (ii) too large, and (iii) optimal. (d) Nearly perfect positioning of an operator in relation to the declination angle. (Reproduced with permission from DP Medical Systems, Ltd) (b, c, Reproduced with permission from DP Medical Systems, Ltd.; d, © Dr Alexander M. Reiter)

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13.24

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13.24 Carborundum, India, and three shapes of Arkansas stones (from left to right). (© Dr Alexander M. Reiter)

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13.25

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13.25 (a) Sharpening stone oil. (b) A few drops of oil are placed on an Arkansas sharpening stone. (© Dr Alexander M. Reiter)

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13.26

(a) The handle of a universal curette is held in the palm of one hand, with the terminal shank positioned vertically and the face of the working end parallel to the floor, and the sharpening stone is held with the fingertips of the other hand and placed against the lateral surface of the working end. (b) Close-up view. (c) Illustration showing that the sharpening stone and the face of the working end should form an angle of approximately 110 degrees. Using light pressure the stone is moved in short up-and-down strokes against the lateral surface of the working end. (d) When sharpening curettes, the stone is also moved around the toe. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.26 (a) The handle of a universal curette is held in the palm of one hand, with the terminal shank positioned vertically and the face of the working end parallel to the floor, and the sharpening stone is held with the fingertips of the other hand and placed against the lateral surface of the working end. (b) Close-up view. (c) Illustration showing that the sharpening stone and the face of the working end should form an angle of approximately 110 degrees. Using light pressure the stone is moved in short up-and-down strokes against the lateral surface of the working end. (d) When sharpening curettes, the stone is also moved around the toe. (© Dr Alexander M. Reiter)

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13.27

(a) Intact metal stack transducer of an ultrasonic insert on top compared with one that is bent on the bottom. (b) An indicator guide is used to determine the extent of bending and wear of the tip of an ultrasonic insert. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.27 (a) Intact metal stack transducer of an ultrasonic insert on top compared with one that is bent on the bottom. (b) An indicator guide is used to determine the extent of bending and wear of the tip of an ultrasonic insert. (© Dr Alexander M. Reiter)

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13.28

(a) Debris emerging from an ultrasonic handpiece. (b) Biofilm inside a cut plastic tube carrying water to an ultrasonic scaler. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.28 (a) Debris emerging from an ultrasonic handpiece. (b) Biofilm inside a cut plastic tube carrying water to an ultrasonic scaler. (© Dr Alexander M. Reiter)

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13.29

(a) Manufacturer lubricant for low- and high-speed handpieces. (b) The oil is inserted into the air entry hole (i.e. the smaller of the two larger holes (*)). (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.29 (a) Manufacturer lubricant for low- and high-speed handpieces. (b) The oil is inserted into the air entry hole (i.e. the smaller of the two larger holes (*)). (© Dr Alexander M. Reiter)

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13.30

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13.30 (a–c) Accidental aspiration of a maxillary canine tooth in a cat, requiring lobectomy for its removal. (© Dr Alexander M. Reiter)

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13.31

Showing owners (a) before and (b) after images of professional dental cleaning can be very inspiring and encourage them to start daily tooth brushing as part of a home oral hygiene regimen for their pets. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.31 Showing owners (a) before and (b) after images of professional dental cleaning can be very inspiring and encourage them to start daily tooth brushing as part of a home oral hygiene regimen for their pets. (© Dr Alexander M. Reiter)

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13.32

(a) Assortment of toothbrushes. (b) Brushes may be made with the hospital name on them. (c) Cat toothbrush with angled head and pointed bristles. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.32 (a) Assortment of toothbrushes. (b) Brushes may be made with the hospital name on them. (c) Cat toothbrush with angled head and pointed bristles. (© Dr Alexander M. Reiter)

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13.33

Toothbrushing in (a, b) a cat and (c, d) a dog. The non-dominant hand is placed in a C-shape around the muzzle of the pet so that the mouth is kept closed. The fingers of that same hand are used to raise the upper lip (and retract the cheek backwards) to make the teeth visible for brushing. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.33 Toothbrushing in (a, b) a cat and (c, d) a dog. The non-dominant hand is placed in a C-shape around the muzzle of the pet so that the mouth is kept closed. The fingers of that same hand are used to raise the upper lip (and retract the cheek backwards) to make the teeth visible for brushing. (© Dr Alexander M. Reiter)

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13.34

(a–c) Bass technique directing the bristles at a 45-degree angle toward the gingival margin. The client should prioritize brushing in areas that collect the most plaque (usually the buccal surfaces of the caudal maxillary cheek teeth) in case the patient becomes uncooperative before the task is completed. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.34 (a–c) Bass technique directing the bristles at a 45-degree angle toward the gingival margin. The client should prioritize brushing in areas that collect the most plaque (usually the buccal surfaces of the caudal maxillary cheek teeth) in case the patient becomes uncooperative before the task is completed. (© Dr Alexander M. Reiter)

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13.35

(a) Left mandibular canine tooth of a dog with severe abrasion on its distal crown surface. The tooth was prepared for receiving a partial (‘three-quarter’) crown. (b) The dental laboratory technician was instructed to not follow the contour of the prepared crown but to make the prosthodontic crown thicker in the area of severe abrasion (arrowed). (c) The cemented prosthodontic crown was fabricated as instructed. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.35 (a) Left mandibular canine tooth of a dog with severe abrasion on its distal crown surface. The tooth was prepared for receiving a partial (‘three-quarter’) crown. (b) The dental laboratory technician was instructed to not follow the contour of the prepared crown but to make the prosthodontic crown thicker in the area of severe abrasion (arrowed). (c) The cemented prosthodontic crown was fabricated as instructed. (© Dr Alexander M. Reiter)

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13.36

Items to be sent to the dental laboratory for prosthodontic crown fabrication: stone models (left top), bite registration (left bottom), and impressions of prepared canine teeth. (© Dr Alexander M. Reiter) © 2018 British Small Animal Veterinary Association

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13.36 Items to be sent to the dental laboratory for prosthodontic crown fabrication: stone models (left top), bite registration (left bottom), and impressions of prepared canine teeth. (© Dr Alexander M. Reiter)