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September 2023
Improving Patient Care with Diagnostic Dental Imaging
Internationally recognized veterinary dental expert Brook Niemiec, DVM, DADVC talks about the benefits of dental teleradiology for the practice, the patient, and the client.
Teleradiology can improve your skills while boosting client confidence
Veterinary dentistry is rapidly becoming more common and accepted as clients become more educated about the best care for their pets. Which means adding or improving on your dental diagnostic imaging is not only good medicine, it’s also economically beneficial.
It has been well established that dental and oral imaging is the single most important way to improve dental diagnoses. For example, nearly one-fourth of uncomplicated crown fractures of maxillary fourth premolars in dogs are, in fact, nonvital. Since this is a condition seen daily in general practice, imaging allows for diagnosis and treatment.
Furthermore, imaging speeds up procedures. Images are required for determining the suitability of crown amputation for feline tooth resorption, and they can help avoid iatrogenic issues—most importantly, pathologic mandibular fractures.
A Radiology Revolution
Digital dental radiology has revolutionized veterinary dentistry in many ways. First, the ability to retake mistakes has led to shorter anesthesia times. Next, the larger format and ability to improve images—either manually or via the preselected filters (algorithms)—markedly improves diagnostic yield.
However, the ability to electronically transfer images is potentially its greatest asset. These can be for clients’ records, a new family vet, collaboration with a specialist, or telemedicine.
Telemedicine and teleradiology have been around for decades, first on the human full-body side and then in veterinary medicine. It is almost standard of care in many clinics to have all studies reviewed by a radiologist. In our dental practice, this is still routinely done; however, on same-day cases, our anesthesiologist is a great backup for chest films.
But while most veterinarians think nothing of sending out a thoracic or abdominal image, they very rarely send out dental studies. This is despite the fact that we spend weeks in vet school learning how to read full-body images but get hardly any instruction in dental radiology.
Not Good Enough
I believe there are two main reasons for this: First, teleradiology is rare in human dentistry [although it is changing with Cone Beam CT (CBCT) scans; see sidebar]. Therefore, clients are not used to having a “dental radiology report” for themselves, let alone their pets. A key difference, though, is that human dentists are extensively trained in reading dental radiographs.
I feel that, while veterinary dentistry has made great strides over the last few decades, it is still commonly undervalued. When this is combined with the fact that untreated and undertreated dental disease almost never results in obvious clinical signs, we fall into “It’s good enough.”
But clearly, it’s not. As a Veterinary Dentist™, I get many reports from general practitioners that are, quite frankly, completely off-base.
- We see a large number of teeth that were extracted but were normal radiographically (and clinically per the dental chart) but were deemed nonvital due to a mental foramen or a “chevron” effect.
- We have also seen many cases of improperly performed crown amputation.
- Finally, a lot of undiagnosed pathology is corrected later at our clinic.
The Next Generation of Veterinary Dental Imaging
The More You Do It, the Better You Get
Reading dental radiographs is a lot of learning by experience. Textbooks and CE courses, either in person or online, are very helpful, but not all cases can be demonstrated in these modalities. It’s just like cat spays—remember how long the first one took? The more you do it, the easier it becomes, and the better and faster you get.
I compare extractions to learning guitar. When visitors come to our classes or our clinic (all are welcome to shadow us), they are amazed at how quick I am at extractions. Well, yes, I am fast, and it’s because I’ve done more than 200,000 in my career. I compare that to the awe I experienced when I first started lessons with my guitar instructor who had been practicing for 30 years.
Veterinary dentists are uniquely suited to reading dental radiographs because it’s what we do all day, every day. If it’s not what you do all day, every day, and you’re working on improving your radiograph reading skills, consider how teleradiology services could help you build proficiency and competence.
Increasing Your—and Your Clients’—Confidence
Teleradiology will greatly improve your diagnostic ability and increase your confidence in your dental recommendations, but you may not be the only one benefitting: One frequently overlooked aspect of teleradiology is that it is, in essence, a second opinion.
In our practice, we see many clients who have refused extractions at their primary vet because they want to know if there are options to save the teeth that were recommended to be extracted. Commonly, we agree with the referring vet—and the client then schedules the extractions.
However, if the GP had a report from a telemedicine service (see STAT reads below) at the outset, the pet could have been spared the second anesthesia and the client would have saved the cost. That being said, there are many cases where advanced procedures could save a tooth, which underlines the value of consultation.
Conversely, we have clients who come to us after the extractions have been performed at their family vet and are upset that they consented to the care. Even when extractions were the best treatment option, a wedge has been driven between the practice and the client. A report from a telemedicine site to back up the practice’s treatment recommendation would have alleviated this issue completely.
Worse, of course, is when we disagree with the therapy and feel that a tooth could have been salvaged, in which case a teleradiology consultation would’ve been even more useful.
An Educational Bonus
A final and underappreciated benefit of dental teleradiology is education.
In the almost 15 years that our telemedicine service has been around, many clinics have learned how to read their own films. Many clinics tell us they had no idea what they were looking at when they started using our service, but they learned case by case. After the first 9 to 12 months, they stopped sending every case and sent only the ones they had questions about.
Not only do these practitioners gain skills in reading films, but the reading dentist also provides invaluable information on treatment options. This is helpful not only for the patient in question but also for future ones with a similar condition. Learning the latest in veterinary dentistry is just an additional benefit.
Common Challenges (and Solutions)
Implementing teleradiology is a fairly straightforward process. Most major diagnostic laboratories have a Veterinary Dentist™ on staff, and there are several veterinary dental–specific options as well.
Teleradiology Troubleshooting
Four Steps to Using a Teleradiology Service
- Pick your service and work with their IT department to determine the flow of the submission.
- Upload images. Once the submission process is set up, upload the images and submit the history to the telemedicine service. (Please do not do this with a pet under anesthesia.)
- Export the report. This can be tricky—see above.
- Review the report. When the report is received, the clinician can go over the report with the client or consult with a specialist to determine the best care.
Veterinary dental teleradiology and CBCT represent the state of the art in imaging for our dogs and cats. Utilizing this technology will greatly improve diagnostic yield and, thus, patient outcome; and incorporating teleradiology consultations will also boost the veterinary team’s confidence in reading radiographs and recommending therapy.
When you also take the time to properly educate pet owners about the value these services represent to their beloved pets, they’ll happily pay the cost, leading to healthy patients and loyal clients.
Brook Niemiec, DVM, DADVC, is recognized internationally as one of the leading authorities in veterinary dentistry. He is a 1994 graduate of the University of California Davis School of Veterinary Medicine and a board-certified specialist in veterinary dentistry in both the American and European Veterinary Dental Colleges (AVDC) as well as a fellow in the Academy of Veterinary Dentistry (AVD). He is one of about 10 veterinarians worldwide to hold all three of these certificates. He is a past president of the AVD, as well as the AVDC delegate to the World Small Animal Veterinary Association (WSAVA). |
Photo credits: DenGuy/iStock via Getty Images Plus