AAHA Dental Anesthesia Mandate Comes Under Fire
The new mandate of requiring anesthesia by the the AAHA has come to meet opposition.
Dental cleanings done without general anesthesia are safe and effective in many cases, according to a pilot study that challenges a new American Animal Hospital Association mandate requiring anesthesia and intubation for all dental patients.
The rule, part of the updated 2013 AAHA Dental Care Guidelines for Dogs and Cats, has a few veterinary hospitals contemplating abandonment of their AAHA accreditation. Many who oppose the mandate have been using anesthesia-free dentistry in their practices for years without problems.
"I totally oppose the policy,” said Kristy Lund, DVM, co-owner of Lund Animal Hospital in Boca Raton, Fla., which has been accredited for more than 25 years. "I’m up for renewal in November and I’m not renewing.”
Dr. Lund has offered non-anesthetic dentistry for seven years.
The study, published in the fall issue of Integrative Veterinary Care Journal, looked at Professional Outpatient Preventive Dentistry (POPD), an anesthesia-free service performed by trained technicians who are qualified by examination by the American Society of Veterinary Dental Technicians and work under a veterinarian’s supervision.
Pet Dental Services (PDS) of Costa Mesa, Calif., and West Palm Beach, Fla., which helped fund the research, carries out 15,000 POPD cleanings a year at veterinary clinics in 11 states.
PDS is one of only a handful of companies that perform anesthesia-free dentistry on veterinarians’ premises and under their guidance. This distinguishes it from lay people who "clean” pets’ teeth in grooming shops, pet stores, boarding facilities and house calls.
The study of 12 cats and 12 dogs found that all the animals tolerated the cleanings without complications.
In the study, the animals’ teeth were cleaned by a trained Pet Dental Services technician and subsequently examined under general anesthesia by a board-certified veterinary dentist.
"The examination consisted of inspection for any remaining subgingival calculus using compressed air, exposed full mouth radiographs and a complete oral exam,” the study reported.
After the POPD was completed, according to the study, the board-certified veterinary dentist found no residual plaque or calculus on any of the dogs or cats. In addition, all the patients for which the technician recommended anesthetic dental treatment were found to have radiographic findings in the specialist’s examination.
"In summary, the POPD was able to perform a complete prophylaxis, scaling supra- and subgingivally thoroughly and safely on all subjects,” the authors reported.
The study was peer reviewed by W. Jean Dodds, DVM, founder of the HemoPet blood bank and diagnostic laboratory in Garden Grove, Calif., and a board member with the American Holistic Veterinary Medical Association.
AAHA President Kate Knutson, DVM, criticized the findings and the study’s credibility, pointing to the "very small” sample size and other statistical and technical aspects.
Dr. Knutson would not rule out relaxation of the AAHA guidelines over time.
"AAHA welcomes more rigorous studies that do a deeper dive into non-anesthetic dentistry,” she said. "In the meantime, we need to consider what is best for the patient.”
Taking part in the study were Stephanie Sur, DVM, of The Whole Pet Vet Hospital and Wellness Center in Los Gatos, Calif., Nova Southeastern University researcher and statistician Patrick Hardigan, Ph.D., and three doctors of dental medicine. With the exception of Hardigan, all are directors of the National Pet Dental Association, a group that promotes non-anesthetic veterinary dentistry.
The research team noted that anesthesia-free dental work using body restraints and behavior management is not appropriate for all cats and dogs.
"It is intended to be a preventive treatment for young patients or as a therapeutic treatment for patients with Stage 1 and 2 periodontal disease,” the study reported. Neither is it intended "to replace anesthetic dentistry but to support it, meaning that it is up to the doctor to decide when and for what patients the service is appropriate,” the authors wrote.
They noted that "if this [had not been] a research setting, the technician would have stopped the POPD after the exam in 62.5 percent of the patients, all of which were [later] found to have radiographic findings, and discussed the findings with the veterinarian.”
AAHA’s new guidelines state that general anesthesia and intubation are necessary in all dental cases to ensure proper assessment and treatment.
The guidelines say that intubation is essential to prevent the aspiration of water and debris during dental procedures. They also state that anesthesia ensures patient health and safety by permitting "immobilization without discomfort, periodontal probing, intraoral radiology, and the removal of plaque and tartar above and below the gum line.”
The mandate has the support of the American Veterinary Dental College.
"Dental experts agree with and endorse AAHA’s new mandatory standard regarding anesthesia and dentistry,” said AVDC President Jan Bellows, DVM, Dipl. AVDC, Dipl. ABVP.
Dr. Bellows helped design and participated in the study’s early stages before stepping aside.
"Once I felt the study was fatally flawed in design and their initial conclusions, I declined any further contribution,” he said.
Bellows did not dispute the finding that the animals he examined under anesthesia after the POPD had no residual plaque or calculus supra- or sub-gingivally.
His objection was to "their conclusions that thorough diagnostics, including tooth-by-tooth probing and cleaning, can be done without general anesthesia. The fact that they missed many areas that we found either through the under-anesthesia, tooth-by-tooth exam leans to the uselessness of non-anesthetic dentistry.”
Patrick Hardigan, Ph.D., counters Bellows’ take. Hardigan is executive director of Health Professions Division Research at Nova Southeastern University in Fort Lauderdale, Fla., and was the statistician on the pilot study.
"The researchers were able to identify all areas of pathology, and confirmed their findings with radiography. Therefore, their research supports the conclusion that a probing and cleaning can be done without general anesthesia.”
Starting Nov. 1, all 3,200 AAHA-affiliated practices seeking reaccreditation must comply with the standard by the time of their evaluation.
Another veterinarian reconsidering AAHA status is James Davis, DVM, who owns accredited hospitals in Jupiter, Fla., and Marietta, Ga. About 12 patients a month at Harmony Animal Hospital in Jupiter get anesthesia-free cleanings through Pet Dental Services, Dr. Davis said.
"We’ve seen the benefits these procedures have for patients,” he said. "Because of the lower cost involved, they are able to get their teeth cleaned a lot more often.
"Bottom line, we clearly have better dental health in our patient base with the non-anesthetic service.”
Anesthesia carries inherent risks, Davis said, using the example of a 7-year-old Cavalier King Charles spaniel, a breed known for elevated odds of heart and dental disease.
"Heart disease can be so severe that there’s no way you’re going to do anesthesia on that dog,” Davis said. "AAHA is telling us that we can do nothing to that dog to clean its teeth, that it’s unethical and that it’s below the standard of care. And that’s unacceptable for us.”
AAHA’s president countered that anesthesia remains the better choice.
"If you have a dog that is not a good candidate for anesthesia, one option is to send it to a facility that does high-risk procedures,” Knutson said. "People need to understand that having severe periodontal disease or an abscessed tooth can be an equal, if not bigger, threat to a pet’s health than a broken leg, for example. If the dog’s leg was broken or it had a bladder stone, most veterinary professionals would still take it to surgery. The same commitment needs to be made to dentistry, either by using anesthesia during the procedure or by partnering with a practice that does.
"Thanks to AAHA anesthesia standards, the risk of adverse anesthesia-related events is minimized,” she added.
Davis emailed both Knutson and his AAHA representative to register his objections to the policy change.
"Basically [AAHA] is telling us that we’re not doing a good job,” Davis said. "The staff is taking it hard. We’re dedicated, well-educated, disciplined professionals who want to do the right thing. But we feel that the change in this policy is clearly going to hinder our dental health program.”
He suggested that AAHA develop guidelines "based on patient selection and how to make this work rather than just pulling the plug on it.”
Knutson stood by the mandate.
"At this time, there are no studies to show that non-anesthetic dentals work as well as charting, cleaning and taking full-mouth X-rays when a patient is intubated,” she said. "As a medical professional, you need to be able to give your client a correct diagnosis.
"It is also a welfare issue,” she added. "We have no idea what stress hormones are released in a pet who is having an awake non-anesthetic dental procedure performed on them. Further research on non-anesthetic dentals is needed before any guidelines by any organization could be developed.”
Davis is considering following Dr. Lund and giving up his AAHA accreditation.
"We haven’t made a final decision, but we are leaning that way,” he said.
AAHA acknowledged that some members may cut ties.
"Whenever we pass new standards there will be members who won’t [abide] and won’t be able to receive accreditation,” communications manager Kate Spencer said. "It won’t necessarily surprise us if not everyone complies.
"The vast majority of what we’ve heard is positive.”