Dentals

The procedure and nursing considerations

Dentals often involve water spraying everywhere and the patient being turned and moved frequently. Before starting, ensure you have plenty of heating aids around to keep the patient warm throughout. 

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Remember to preoxygenate prior to intubation and, if you are performing a dental on a feline, make sure you wait the full 30-90 seconds for the Intubeaze to work prior to intubating. Tubes can often become dislodged during dentals, so be mindful of how you tie the ET tube to the patient at the start - around the back of the head often works better than around the muzzle or lower jaw for these procedures. 

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I like to place several inco sheets underneath the patient's head when setting up, as I can quickly move these out once each one becomes wet and there is a fresh sheet underneath to keep the head area clean and (relatively) dry. I personally find this technique better than the dental mats that are available, but find what works best for you.

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The best practice is to chart and grade all teeth prior to scaling and polishing and extractions by using a dental probe. More information on dental charting can be found here. Ideally, if your practice has access to it too, I would always recommend taking full mouth dental x-rays too as it can give a better picture of the oral health. This should be taken as standard in feline dentals now too, due to risk of FORLs. 

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During dentals often the patient can get hands resting on their heads and faces, so it is important to check and re-lubricate eyes throughout. 

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Monitor capnography traces throughout as these can tell us whether the ET tube has become dislodged or bent during the procedure.

Ideally we want to be placing local nerve blocks in the mouth before removing any teeth and when these work, they can provide great analgesia to the patients, but sometimes further rescue analgesia is needed. Paracetamol can be given if it hasn't been used already (10-20mg/kg slow IV) or, if very severe pain response is seen, a one off dose of ketamine can be used (0.5mg/kg IM or slow IV) or fentanyl (5μg/kg slow IV). Be mindful for signs of apnoea if giving ketamine or fentanyl. Fentanyl can also slow heart rate too so be aware of this if giving.

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High risks in dental procedures are often due to bleeding as well as damage to the eyes when performing maxilliary blocks or removing upper molar and premolar teeth (especially in felines and small dogs). Damage to the mandibular symphysis can also be a risk, especially when the surgeon is removing lower canines. 

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Ensure that you are not using mouth gags in feline patients too as there is risk of causing blindness due to impeding the arterial blood flow when the jaw is wide open for extended periods of time.

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Remember to remove any throat packs before waking the patient up as well as monitoring for any signs of visual issues or swelling around the face and throat in recovery.