WSAVA Nov 2021 Proceedings - Flipbook - Page 45
IV
Large amounts
of subingival
calculus
Severe inflammation, Gum recesOver 50% support
sion, Pus, Gums
loss
bleed easily, Deep
pockets
0020
Severe, advanced
Periodontitis,
Irreverble, Furcation III
Treatment
PAIN MANAGEMENT FOR CANINE AND FELINE
DENTAL PATIENTS
B. Ong
Serdang/Malaysia
Treatment depends on the periodontal disease grade and the specific
findings. For initial stages, supra-gingival scaling (removal of plaque and
calculus above the gingival margin [1]) and polishing (smoothing the
roughness caused by scaling and removing any remaining plaque and
stained particles [1]) under GA would be sufficient. Moderate periodontitis needs sub-gingival scaling and root planning (SRP), together with
long acting topical antibiotic preparations to stop further damage. Root
planning is the removal of the superficial layer of toxin laden cementumfrom the root surface [1]. This produces smooth root surface, reducing
accumulation of plaque, and also increasing epithelial re-attachment.
Shallow periodontal pockets are treated in a closed fashion, but pockets >
6 mm deep require flap surgery to expose root surface to ensure adequate
cleaning.[2][5] Guided tissue regeneration techniques/bone grafts etc. can
reverse the bone loss at moderate levels of periodontitis. Advanced periodontal disease stages with > 50% attachment loss needs extraction of
the affected teeth as corrective measures. Systemic antibiotics (that act
against Gram negative anaerobic bacteria) such as clindamycin, Augmentin, metronidazole, doxycycline, azithromycin etc. may also be used when
necessary. Moreover, complicated pathology like mandibular fractures,
oronasal fistulae etc. need their specific corrective surgical procedures.
Qualifications:
Prevention/Management
MULTIMODAL ANALGESIA FOR DENTAL PATIENT
Prevention of supra-gingival and sub-gingival plaque accumulation is
the baseline [5]. The benefit of any professional periodontal therapy is
short-lived unless maintained by effective homecare [1]. This will also
reduce the need for frequent professional scaling and polishing. Proper
client education is a key factor here. Education of all the staff members of
veterinary practices too is of paramount importance.
The mainstay of dental pain management for the canine and feline
species is opioid, dental nerve block, and non-steroidal anti-inflammatory drugs (NSAIDs). The multimodal analgesia approach is preferably
employed because it requires a lower dosage of multiple analgesic drugs,
which results in fewer adverse effects. Different analgesic agents act at
the different sites of the pain transmission pathway. For example, NSAIDs
reduce nociceptor sensitization during dental extraction by reducing
inflammation around the affected areas; regional anesthesia blocks the
transmission of pain impulses along the nerves from the nociceptor to the
brain stem; whereas a full mu-opioid agonist binds to the receptor at the
spinal cord and brain which inhibits pain modulation and perception.
References
• Crossley DA, Penman S. BSAVA Manual of Small Animal Dentistry.
2nd Edition. BSAVA, UK. 1995.
• Niemiec BA. Small Animal Dental, Oral and Maxillofacial Disease. Taylor
& Francis Group, Boca Raton, FL. 2012.
• Perry R, Tutt C. Periodontal disease in cats: Back to basics--with an eye
on the future. J. Feline Med. Surg. 2015. PubMed.
4. https://www.smalldoorvet.com/learning-center/medical/periodontal-disease-in-dogs
5. https://www.msdvetmanual.com/digestive-system/dentistry/periodontal-disease-in-small-animals#v3261247
Full name: Benedict Ong Huai Ern
Qualifications: Doctor of Veterinary Medicine (DVM), Master of Veterinary
Medicine (MVM), Doctor of Philosophy (Ph.D.)
Email: benedict@upm.edu.my
WHY PAIN MANAGEMENT IS RELEVANT IN EVERY PRACTICE?
Dental pain can be excruciating especially when it is undertreated in
canine and feline patients. As many of the patients who undergo the
dental procedure are geriatric patients, they often have other co-existing
diseases such as renal and cardiac diseases and have high anesthetic
risk. With proper pain management, the requirement of general anesthesia
could be reduced, which minimizes the cardiovascular and respiratory
depression secondary to general anesthesia. Post-operatively, the patients
with less general anesthesia requirement will have a shorter recovery time
from general anesthesia. As the dental pain is alleviated, they will have a
better appetite and smoother recovery.
OPIOID & NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
In dogs, full mu-opioid agonists (for example, morphine and fentanyl) are
commonly used for moderate to severe pain such as dental pain. The possible adverse effects of administrating morphine before the anesthesia
induction is nausea and vomiting in dogs. Therefore, it is recommended
to administer morphine intramuscularly after induction and intubation,
before the dental procedure in dogs. A full mu-opioid agonist may cause
dysphoria and hyperthermia in cats. However, such concern should not
impede the use of opioids in the pain management of the feline species,
because the high effectiveness of opioids outweighs the adverse effect of
poor pain management.
Non-steroidal inflammatory drugs (NSAIDs) are added to complement the
pain management quality for a dental procedure and have anti-inflammatory properties. However, it is important to assess the patient’s condition
before administering NSAIDs to ensure the patient is well-hydrated,
normotensive, has no coagulopathy, and has no unstable kidney disease.
If it is administered pre-operatively, blood pressure must be monitored
throughout the anesthesia procedure to ensure that it is normotensive. For
patients that are prone to hypotension secondary to general anesthesia,
the author prefers to administer NSAIDs after the general anesthesia is
discontinued.
45