Practical Dental Series: Practice Building – Dental Services: Good Medicine for Patients & Practices

As originally published in “Today’s Veterinary Practice,” Sept/Oct 2011 (Volume 1, Number 2)

Brook A. Niemiec, DVM, FAVD, Diplomate AVDC

This is the first article in our Practical Dentistry series, which will present various ways of increasing revenue through offering dental services in the general veterinary practice.

This series will present techniques and procedures that require minimal expense, effort, and training, yet have proven to be invaluable in many practices (general and referral). All of the information and procedures discussed promote good medicine and, therefore, are highly beneficial for the patient as well as the practice.

Why Is Marketing Dental Services Important?

Common Disease with Significant Repercussions

Oral disease is one of the most common diseases in veterinary medicine, but clinical signs are generally subtle or absent.1,2 Patients with dental disease are often in pain despite lack of clinical signs.3,4 In addition, many oral disease processes cause significant localized and systemic medical problems.5-8

Lack of Knowledge = Undertreatment

The general public and veterinary field’s lack of knowledge about dentistry is dramatic. This results in patients being undertreated. Providing proper dental therapy to more patients is good medicine for pets and good business for the practice.

Happy Patients & Clients

A healthy mouth makes a big difference in the health and attitude of your patients. By increasing the pet’s demeanor and quality of life, you will strengthen your relationship with the client.

Loss of Traditional Veterinary Revenue

Over the last decade or so, there has been a significant loss of traditional veterinary revenue streams due to many factors, including improved knowledge and outside competition.

  • Vaccines: Some immunologists do not feel that annual vaccines are needed.9 While there is still controversy associated with this topic, it has impacted practice income. Better client education on the importance of regular health examinations and wellness assessments, including dental services, can offset changes in vaccination protocols.
  • Online pharmacies: With the increasing popularity of online pharmacies, significant income is lost from prescription revenue. This trend started with flea control and heartworm prevention products, but now more commonly affects all veterinary prescriptions.
  • Internet reliance: Increased reliance on the Internet and other sources decreases client trips to the clinic.

What Do the Numbers Tell Us?

Dogs

  • 80% over 2 years of age have periodontal disease1
  • 25% (conservative estimate) have uncomplicated crown fractures10
  • 10% have fractured teeth with pulp exposure (complicated crown fractures)11
  • 5% have other dental conditions, such as neoplasia, orthodontic problems, and caries10

Cats

  • 70% have periodontal disease1
  • 40% have tooth resorption12
  • 10% have other dental conditions, including tooth fractures10

Learn more about complicated versus uncomplicated crown fractures by reading Dr. Niemiec’s article Diagnosis & Treatment of Crown Fractures (Today’s Veterinary Practice, July/August 2011), available at todaysveterinarypractice.com, or by viewing an educational video at dogbeachdentistry.com

How to Increase Dental Revenue

There are 4 components that help improve income generated from dental services:

  1. Increase number of dental procedures performed
  2. Increase number of dental service options
  3. Improve pre-operative testing protocols
  4. Provide superior intra-operative and postoperative care.

All these components are synergistic; therefore, by increasing 2 or more, an exponential improvement occurs.

See Practice Step by Step: Bonded Sealant Application for Crown Fractures (Today’s Veterinary Practice, July/August 2011) for step-by-step instructions on applying bonding agents to uncomplicated crown fractures, available at todaysveterinarypractice.com.

1. Increase number of dental procedures performed.

This is the most important of the 4 methods and the quickest way to increase revenue. There are several ways to increase your procedure numbers, but the first and foremost is education.

Client Education: If your dental examination and recommendations consist of glancing in the mouth and saying, “Yes, he needs a dental,” you are not going to do many dental procedures.

  • The most successful client education comes from the entire staff, including veterinarians, technicians, assistants, and especially receptionists.
  • The best way for practice owners/managers to get the entire staff on board is to educate the staff and then provide incentives to encourage them to market dental procedures (see Dental Marketing Incentive Plans, page 41).
  • The receptionists, technicians, assistants, and veterinarians should all be well versed in what a complete dental prophylaxis entails, how it benefits the patient, and how to effectively communicate this information to clients.
  • See Educational Resources for Veterinary Professionals & Clients for websites, continuing education opportunities, and reading materials that will provide insightful information.
  • Client education should start with existing clients, but then expand to educating the local population of pet owners. There are numerous methods to provide this education, including:
    • Personal communication from the practice’s staff
    • Handouts/books (Figure 1)
    • Websites of veterinary dentists
    • Your own practice website
    • Practice newsletter or magazine articles.
figure 1

Figure 1. Excerpts from books, journals, and other materials can be used for education; however, permission must be requested from the publisher. This page is from Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. Niemiec BA (ed). London: Manson Publishing, 2010.

Superior equipment: Once the marketing plan is underway and the dental schedule is filling up, superior equipment will speed procedures and increase efficiency.

  • Old, dull, or damaged equipment not only creates the potential for injury, but is far less effective (Figure 2). For example, damage to the last 1 mm of an ultrasonic scaler tip renders it 25% less efficient, and 2 mm loss results in 50% less efficiency.13
  • A new drill, ultrasonic scaler, elevator, or curette can markedly cut down on surgical time and increase the number of procedures performed each day. This minor investment can make a big difference.
  • It is important to note that (1) time is money and (2) decreased anesthetic times are better for patients. If a practice can do 1 more procedure a day, 5 days a week, at an average retail cost of $400, the practice makes an additional $8000 a month. This can easily cover many upgrades in dental equipment.

figure 2 a

Figure 2 b

Figure 2. Examples of poorly maintained and damaged equipment: using equipment in this condition will prolong procedures, increase replacement costs, and potentially harm patients. Courtesy Dr. Jerzy Gawor.

Equipment care & maintenance: Dental equipment must receive proper care. Quality maintenance improves efficiency, increases lifespan of the equipment, and maximizes your investment. Technicians/assistants should properly maintain power equipment, which includes:

  • Oiling handpieces and maintaining compressor oil if necessary
  • Care and sharpening of hand instruments, which is critical but often poorly performed, if at all. Hand scalers should be sharpened at least weekly; daily is ideal.
  • Maintaining and sharpening elevators, scissors, etc
  • Cleaning, drying, and sterilizing dental instruments (Figure 3).

Continuing education/training: Most veterinarians and technicians do not receive enough dental training. In addition, dental techniques and equipment options change and advance at a rapid pace.

  • Ideally, training is attained via hands-on wetlabs (Figure 4). This will benefit the patient, practice, and staff (see Educational Resources for Veterinary Professionals & Clients).
  • By learning new techniques, veterinarians and technicians will perform high-quality dental procedures in less time.
Figure 3

Figure 3. Image of a properly cleaned and packed extraction kit in its sterilization cassette, which is ready for autoclaving. Proper care improves instrument performance and lifespan.

Figure 4

Figure 4. The author providing hands-on dental radiology training. This type of training greatly improves speed and quality of dental radiology in practice. Courtesy San Diego Veterinary Dental Training Center.

2. Increase number of dental service options.

Increasing the number of dental service options is one of the easiest ways to increase your clinic’s dental service revenue. The most efficient way to do this is to offer superior basic care, which should include:

  • Dental radiology (Figure 5)
  • Root planing/application of antibiotic gels (Doxirobe, pfizer.com)
  • Regional anesthesia (nerve blocks) (Figure 6)
  • Proper pain management (opiates, nonsteroidal anti-inflammatory drugs [NSAIDs], morphine/lidocaine/ketamine mixture [MiLK])
  • Bonded sealant agents.

These treatment options will greatly increase patient care and practice income without a significant investment of time or money. Most of these topics will be covered individually in detail in future articles in the series.

Figure 5

Figure 5. The author discussing radiographic findings with a client. The detail, size, and ability to “mark” them (ie, with arrows) improves client understanding and compliance with treatment recommendations. Courtesy of vetdentalrad.com.

Figure 6

Figure 6. Infraorbital nerve block being administered during dental surgery in a dog. Nerve blocks improve patient recovery, decrease monitored anesthesia care, and reduce pain, leading to greater patient comfort and client satisfaction.

Dental radiology: With regard to dental services, dental radiology provides the greatest return on investment.

  • Professional radiology reviews (by a board-certified dentist) will help increase the number of dental treatments performed because the specialist will be able to determine if any pathology is present that requires treatment.
  • Due to the large variations in cost and quality of dental radiology systems, prepurchase consults with equipment manufacturers are recommended in order to help the practitioner decide what system is best for the practice.

Complex procedures: I do not recommend that general practitioners perform more difficult procedures, such as root canals, jaw fracture repair, and major oral surgery. Patients should be referred to a dental specialist that has the experience required for successful outcomes. In addition, more income can be generated, with less stress and expense, by spending that time performing office calls and other typical procedures.

Dental Marketing Incentive Plan

Incentives are a great way to get the entire practice staff on board with a marketing program. Financial rewards improve staff morale and camaraderie by setting a common goal that motivates employees both individually and as a team.

Step 1: Establish the revenue increase goal; 20% to 25% is a good goal.

Step 2: Set time frame for the program: 6 months works well. Any shorter is not enough time to establish the program and any longer may endanger staff motivation.

Step 3: Determine the net revenue from dental services. For most practices, this is approximately 50% of the gross gain from dental services.

Step 4: Calculate the amount of revenue that will be generated during the incentive period: If dental services generated $100,000 during the first 6 months of 2011 and you want to increase that by 20%, dental services will need to generate $120,000 during the first 6 months of 2012.

Step 5: Take a percentage of the increased revenue (in this case, 50% or $10,000) and give it to the staff. This could be in the form of a cash bonus or trip (perhaps one that is combined with a continuing education opportunity).

Step 6: Post a chart tracking dental revenue increases so the entire staff can follow the practice’s progress.

While you will not be collecting any extra income the first 6 months of 2012, you will have changed the entire staffs’ motivation, leading to long-term increased income.

3. Improve pre-operative testing protocols.14

This step improves the safety of each procedure and increases the practice’s revenue:

  • Complete blood panel: Renal and hepatic indices, CBC, and thyroxine testing
  • Urinalysis: Especially useful for assessing slightly elevated renal indices in cats by concurrently evaluating urine specific gravity
  • Chest radiographs: More than 50% of patients > 6 years of age have significant findings on chest films; in addition, hypertrophic cardiomyopathy is often not ausculted.15

4. Provide superior intra-operative and postoperative care.16,17

Provide superior intraoperative care:

  • Temperature maintenance: Circulating warm-water or warm-air blankets (eg, Bair Huggers, arizant.com) (Figure 7)
  • Monitoring: Blood pressure measurement, electrocardiogram, carbon dioxide monitoring, etc
  • IV fluid administration for hydration support and medication administration.
Figure 7

Figure 7. A properly maintained patient under general anesthesia; note that a circulating warm-water blanket is under the patient and a circulating warm-air blanket on top (the air blanket is normally covered with a towel).

Provide superior postoperative treatment:

  • Pain management: Opiates, NSAIDS, local anesthetics, acupuncture, etc.
  • At-home care: Oral cleansing formulas (eg, MAXI/GUARD, addisonlabs.com), plaque prevention (eg, OraVet, pfizer.com), dental home care kits
  • Follow-up appointments and regular dental care

Dentistry is an area of veterinary medicine that offers incredible potential to improve both patient health and clinic revenue. Just by performing proper and thorough dental work, practitioners can greatly increase the overall health of their patients as well as their dental income. A win-win situation for all involved.

MiLK: morphine/lidocaine/ketamine
NSAID: nonsteroidal anti-inflammatory drug(s)

Educational Resources for Veterinary Professionals & Clients

Websites

The following websites provide an extensive repertoire of information and educational materials for both veterinary staff and pet owners:

  • American Veterinary Dental College:
    avdc.org
  • American Veterinary Dental Society:
    avds-online.org

The author is affiliated with the following websites that provide comprehensive dental information to owners and veterinary professionals and teleradiology services for veterinary dentistry, respectively:

  • Southern California Veterinary Dental Specialties:
    dogbeachdentistry.com
  • VetDentalRad.com:
    vetdentalrad.com

Continuing Education

  • American Veterinary Dental Forum (veterinarydentalforum.com): Annual conference that provides continuing education, including hands-on wetlabs, exhibit hall, and many other educational activities. In addition, the website provides a calendar of continuing education opportunities.

The author is affiliated with the following continuing education opportunities:

  • Santa Barbara Veterinary Conference (sbvdtc.com): Annual conference that provides continuing education, including hands-on wetlabs, with a focus on keeping groups small to maximize learning
  • San Diego Veterinary Dental Training Center (vetdentaltraining.com): Continuing education classes that are held throughout the year in San Diego and split into groups by experience level

Books

  • Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. Niemiec BA (ed). London: Manson Publishing, 2010.
  • Blackwell’s Five-Minute Veterinary Consult Clinical Companion Small Animal Dentistry. Lobprise HB. Ames, Iowa: Wiley-Blackwell, 2007.
  • The Smile Book V: The Oral Assessment, Treatment and Prevention Visit. Bellows J. Duluth, Georgia: Pfizer Animal Health, 2006 (oravet.us.merial.com/eextras/60321smile.pdf).

References

  1. University of Minnesota Center for Companion Animal Health. National Companion Animal Study. Uplinks 1996; Feb:3.
  2. Lund EM, Armstrong PJ, Kirk CA, et al. Health status and population characteristics of dogs and cats examined at private veterinary practices in the United States. JAVMA 1999; 214:1336-1341.
  3. Niemiec BA. Endodontics. Vet Clin N Am Small Anim Pract 2005; 35(4):837-868.
  4. Holmstrolm SE, Frost P, Eisner ER. Anesthesia and pain management in dental and oral procedures. Veterinary Dental Techniques, 2nd ed. Philadelphia: Elsevier Saunders, 1998, pp 481-496.
  5. Mealey BL, Klokkevold PR. Periodontal medicine: Impact of periodontal infection on systemic health. Carranza’s Clinical Periodontology. St. Louis: Saunders, 2006, pp 312-329.
  6. Debowes LJ, Mosier D, Logan E, et al. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996; 13(2):57-60.
  7. Pavlica Z, Petelin M, Juntes P, et al. Periodontal disease burden and pathological changes in the organs of dogs. J Vet Dent 2008; 25(2):97-108.
  8. Niemiec BA. Periodontal disease. Top Comp Anim Med 2008; 23(2):72-80.
  9. Schultz RD. Current and future canine and feline vaccination programs. Vet Med 1998; 93:233-254.
  10. Personal experience of the author
  11. Golden AS, Stoller NS, Harvey CE. A survey of oral and dental diseases in dogs anesthetized at a teaching hospital. JAVMA 1982; 18:891-899.
  12. vanWessum R, Harvey CE, Hennet P. Feline dental resoptive lesions. Prevalence patterns. Vet Clin North Am Small Anim Pract 1992; 22(6):1405-1416.
  13. Bellows J. Small Animal Dental Equipment, Materials, and Techniques: A Primer. Ames, Iowa: Wiley-Blackwell, 2004.
  14. Huffman LJ. Oral examination. In Niemiec BA (ed): Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. London: Manson, 2010, pp 39-61.
  15. Paige CF, Abbott JA, Elvinger F, Pyle RL. Prevalence of cardiomyopathy in apparently healthy cats. JAVMA2009; 234(11):1398-1403.
  16. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol 2008; 22(4):659-668.
  17. Broadbelt DC, Pfeiffer DU, Young LE, Wood JLN. Results of the confidential enquiry into perioperative small animal fatalities regarding risk factors for anesthetic-related death in dogs. JAVMA 2008; 233(7):1096-1103.

c05_authorBrook A. Niemiec, DVM, FAVD, Diplomate AVDC, is chief of staff of Southern California Veterinary Dental Specialties, with offices in San Diego and Murrieta, California, and Las Vegas, Nevada (dog beachdentistry.com). He has authored many articles and chapters, including the recently published Small Animal Dental, Oral and Maxillofacial Disease: A Colour Handbook. Dr. Niemiec founded the veterinary dental telemedicine website vetdentalrad.com, which also offers instructional videos and educational posters. He lectures extensively at national and international conferences and is the coordinator and instructor of the San Diego Veterinary Dental Training Center (vetdentaltraining.com). Dr. Niemiec received his DVM from University of California-Davis.