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Opinions Vary on NAD Procedure

By Somyr McLean Perry For Veterinary Practice News

Posted: January 30, 2014, 12:45 p.m. EDT

Nackers is a 14-year-old spayed female pug with moderate tartar buildup and mild inflammation of the gums. She is a patient of Amy Moon, DVM, at Animal Medical Clinic in Bountiful, Utah, and her last non-anesthetic dental was in mid-December.

Dr. Moon said that like many of her patients, Nackers is an ideal candidate for a NAD. "Patients that have a small amount of tartar and gingivitis are good candidates,” Moon said.
Not all veterinarians agree.

In August, the American Animal Hospital Association announced a revision to its dentistry standards, mandating that all dental procedures at member clinics be performed under general anesthesia with patients intubated.

"The 2005 dental guidelines presumed that general anesthesia was the only way to correctly perform charting, cleaning and full mouth X-rays,” said Kate Knutson, DVM, president of AAHA. "The 2005 guidelines emphasize the necessity for dental X-rays, but the 2013 guidelines emphasize that full-mouth X-rays need to be standard with every procedure. Because full-mouth X-rays are difficult to take on an awake animal, general anesthesia is then also necessary in order to properly take full-mouth X-rays.”

NAD Polishing
NAD Polishing.

AAHA member clinics that violate the new mandate by performing dental cleanings without general anesthesia are at risk of losing their accreditation, which has caused controversy.

"We’ve heard from accredited hospital owners who say they will not renew their accreditation when they are up for re-evaluation,” Dr. Knutson said. "However, we have also heard from accredited hospitals practicing non-anesthetic dentals that they will stop doing the procedures in order to keep their accreditation.”

While some veterinarians perform non-anesthetic dentals on their own patients, two major players have emerged that provide non-anesthetic dental cleaning services on behalf of veterinary clinics: Pet Dental Services of Costa Mesa, Calif., and Lake Worth, Fla., and Animal Dental Care of Newport Beach, Calif.

Both companies provide non-anesthetic dental cleaning services exclusively to veterinary clinics. This is an important distinction as many non-veterinary establishments, such as grooming parlors and pet shops, sometimes claim to provide teeth scaling for pets.

In-clinic work
Both these companies work in tandem with veterinary staff to perform the NAD on pets deemed eligible by a veterinarian.

"A dental procedure is a medical procedure that requires the direct supervision of a licensed veterinarian, and must be performed by a highly trained technician,” said Joshua Bazavilvazo, chief executive officer of Pet Dental Services. "The risk of having a pet’s teeth cleaned by an uneducated layperson with little or no formal training could be hazardous for a pet.”

Opponents, however, say that non-anesthetic dentals shouldn’t be performed at all—not even by veterinarians.

"There are more and more practitioners and diplomates of the AVDC addressing this new procedure,” said Barden Greenfield, DVM, Dipl. AVDC, who sits on the board of the American Veterinary Dental College.

"AVDC diplomates understand the risk of NAD more than other veterinary groups due to our advanced dental education, so it is important for us to let both veterinarians and the general public know the potential consequences of a NAD procedure.”

Dr. Bazavilvazo and Michael Borin, DVM, of Animal Dental Care, stress what they believe to be the greatest misconception about non-anesthetic dental procedures—that a NAD is a replacement for a traditional anesthetic dental with full-mouth radiographs.

"NADs do not replace regular anesthetic procedures,” Dr. Borin said. "Most of the misconception about anesthesia-free dental cleanings has been perpetuated by veterinarians who have not seen the procedure performed by a professional company.”

Veterinarians who use PDS’s or ADC’s services, including Dr. Moon who works with Animal Dental Care, said they—and their clients—are very happy with the procedure and its outcome.

Shelley Epstein, VMD, owns AAHA-accredited Wilmington Animal Hospital in Wilmington, Del., and she works with Pet Dental Services. In her practice, adding a less-expensive and less-invasive option for dental care has prompted a greater interest among pet owners to learn about dental care and have their pets’ teeth examined more regularly. 

"We know how many thousands of dogs and cats we see in the office each year,” Dr. Epstein said.

"We know that the majority of them have some degree of periodontal disease. Yet we were doing only about 150 dentistries a year. Now, we are performing an increasing number of anesthetic dentals since using PDS, in part because all of our vets are looking in more detail at each mouth, and in part because PDS is discovering pathology and then recommending anesthetic procedures.”

Moon said initially she was concerned that people would stop anesthetic dental procedures if there was a cheaper option. "But is all about communicating why one [procedure] works better for one patient or the other,” Moon said.

But Greenfield says non-anesthetic dentals have no benefits for any patient.

"While the buccal crown of the tooth may look clean after a NAD procedure, gingival curettage to remove subgingival plaque and calculus cannot be performed on a non-sedated pet,” Greenfield said.

But proponents say curettage can, indeed, be done on awake animals—and that they do so.

Some veterinarians take a middle-of-the-road approach, using mild sedation when appropriate.

Moon describes how every effort is made to calm the pet and keep it calm throughout the procedure.
"The dental technician takes the patient into a very quiet room and speaks quietly and calmly to the patient,” she said. "Sometimes a towel wrapped around the body is all the restraint necessary to clean the teeth (using an ultrasonic scaler), including subgingival scaling and polishing. Occasionally, some patients require a small dose of tranquilizer to have their teeth cleaned.” 

NAD technicians get extensive training
Animal Dental Care of Newport Beach, Calif., and Pet Dental Services of Costa Mesa, Calif., and Lake Worth, Fla., are two companies performing non-anesthetic dental cleanings in veterinary clinics across the country.
Opponents of NAD are concerned about the process, including the credentials of those performing the procedures. While each company has its own process for training its NAD technicians, staff at both companies undergo strict pet dental training as well as written and practical tests.
"I know that both ADC and PDS take [staff training] very seriously and make sure that it is a good medical procedure in every circumstance for each individual animal,” said Michael Borin, DVM, of Animal Dental Care.
Among a number of other requirements, ADC staff must have a minimum of two years’ experience working in a veterinary hospital as a technician or medical assistant, 800 hours of training, including performing cleanings while supervised by a CPCDT--certified preventive care and assessment technician--and passing reviews by veterinarians from different hospitals, Dr. Borin said.
In the past, ADC didn’t require its NAD technicians to be certified veterinary technicians, but it is making that change, he said, and all current technicians are in the process of obtaining certification.
"Although PDS employs CVTs and RVTs, along with technicians who have B.S. degrees in Animal Science, PDS has its own specific training program to ensure the utmost educated, capable technicians, who practice on a level that mimics human dental hygiene,” said CEO Josh Bazavilvazo.
"All PDS technicians are level 1 certified by the American Society of Veterinary Dental Technicians, are pet first aid/CPR certified by the American Red Cross, and have a minimum of three years of experience working in a veterinary hospital as a veterinary technician.
"They are instructed over a six-month period with a training program developed in part by PDS’ on-staff board-certified periodontist and overseen by multiple veterinarians in the field.”

She noted that fractious or wiggly patients don’t make the cut for the non-anesthetic dental option, and pets with teeth that are mobile, abscessed or show signs of significant periodontal disease require dental radiographs, exam and cleaning under general anesthesia.

Krista Gibson, DVM, owner of Animal Medical Services in Scottsdale, Ariz., used to perform NADs herself, but her experience was less than positive for her patients and she now believes that the procedure itself is flawed.


"I found them to be woefully inadequate for preventing serious dental and periodontal disease,” she said. "Sure, they made what parts of the teeth owners can see prettier, and the pets generally smelled better for a couple of days, but I was not doing my clients any favors by not educating them regarding the safety of modern veterinary anesthesia and the risks associated with NADs.” 

Liability Questions
Dr. Gibson agrees with Greenfield’s assessment that veterinarians performing NADs in their clinics open themselves to liability. "The biggest liability is that of omission,” Greenfield said. "The veterinarian is contracted with the [pet] owner to perform dental assessment and treatment. If, because of lack of proper assessment (probing and dental X-rays), proper treatment is not provided, the animal suffers and the veterinarian is liable.”

Greenfield admits that he’s never actually witnessed a non-anesthetic dental cleaning, only clinical images and radiographs of pets who had received an NAD.

However, Dr. Knutson of AAHA witnessed one company and two of its employees perform the procedure on both cats and dogs.

"I was impressed by the ability of the registered technicians to evaluate pathology,” Knutson said. "The emphasis placed on positive behavioral reinforcement for the patients was excellent. The two individuals I watched had been trained and knew what they were doing.”

Is there a compromise?
So if proponents of NADs are having similar positive experiences and the companies that conduct the procedure, why do AAHA regulators say they can’t be done?

"Many animals receiving NAD are not candidates for it,” Knutson said. "They have pathology in their mouths that needs to be addressed with X-rays and often surgery. Just because something is being done doesn’t mean it is being done correctly or in the best interest of the pet.”

Bazavilvazo seems to understand Knutson’s point and believes that fear was the major catalyst behind the recent AAHA mandate.

"The main problem opponents have is the lack of standardization among NAD practitioners,” he said, but he added that AAHA’s decision was anecdotal based on certain individual perceptions of the procedure.
"Opponents know first hand that a thorough prophylaxis can be performed by a trained PDS technician,” Bazavilvazo said. "This has been proven by a double-blind pilot study conducted first-hand with a board-certified veterinary dentist.”

Bazavilvazo is referring to a pilot study published in the fall of 2013 by the Integrative Veterinary Care Journal in which 12 dogs and 12 cats were evaluated before and after a non-anesthetic dental procedure.

But Greenfield doesn’t buy it.

"There is no scientific-based research in any dental textbook, or in a nationally recognized journal that supports NAD,” he said. "Any information written has been via Level 4 Evidence Based Medicine,  which is only anecdotal.” 

Proponents of the procedure hope that further discussion and research on NAD will open the door to the AVDC and AAHA reconsidering their positions and working with proponents to create standards that everyone agrees on.

"I think AAHA will reverse its decision at a later time,” Epstein said. "Veterinarians are realizing that there is a need for this procedure, that it is now performed by skilled professionals, and it is highly practical to introduce it to their practices.”

AAHA’s board of directors would welcome new scientific evidence evaluating the efficacy of NAD to broaden knowledge about the procedure. But working toward creating standards would be complicated.
"Standardizing NAD would require a number of different fields to come together: dental, anesthesia, pain management and behavior,” Knutson said. "And it would involve acquisition of communication skills by general practitioners and their teams so the public would understand exactly what benefits their pets are receiving from NAD and the potential risks of such a procedure.”



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