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Saturday, September 5, 2015

Are Dental X-Rays Necessary?

Jennifer brought up an important topic of discussion....

Jesse, my Chi mix, had mobile incisors and needed a dental cleaning and 6 incisor extractions. I chose a veterinarian who had great credentials and specializes in dentistry although not a dentist. I felt somewhat comfortable with her over my regular vet since she does dentistry daily. I even paid $1000 instead if the typical $600 just for her. After the surgery I asked for details and found out the vet did not do post extraction X-rays. I'm very mad and I'm very worried. I know that a cautious dr would have taken post X-rays and not just pre. The dr told me she knows she got the entire tooth but from reading the aaha website I don't know that she can determine this unless she has a super power. Please tell me your thoughts and hopefully you will have encouraging words. She's offering to attempt to do awake radiographs but I refuse to traumatize a rescue dog anymore than he ready is unless for some reason he remains calm. Please help!

This very issue is a subject of much debate in veterinary medicine.  Up until the last 10-15 years we really didn't have easy access to dental radiology, so the vast majority of the profession performed extractions and basic dentistry without such imaging techniques.  And most of the time things went without a hitch!  The problem is that you can't assess fine details without x-rays, including the possibility that some of the tooth was left behind.
Dental x-rays are not taken with the standard machine that pretty much every vet has.  The ones that we use for 99% of x-rays do not give the detail and clarity needed for dentistry.  Sure, we can take images of the jaw and teeth, and I've certainly detected issues this way.  However, it is not as precise as a machine specifically designed to radiograph the teeth.  You can see much more detail with dental x-rays, and find things that a standard x-ray machine would miss.  It is also possible to position the mouth in such a way that teeth are isolated and not overlapping, which you can't easily do with standard machines.  However, performing dental x-rays requires a completely different set of equipment, and that stuff isn't cheap.  The main reason why more vets don't have dental x-rays is in large part due to the cost of having it, and then being able to recoup that investment.

If you talk to the dental specialists or those really into veterinary dentistry, they'll tell you that you should never do extractions without pre- and post-extraction x-rays, and that you can't tell which teeth need extracting without those images.  In principle I do agree with the specialists.  But this is in an ideal world where dental radiology equipment isn't an expensive investment and clients are willing to pay double or triple normal dentistry costs to cover that additional service.  In the real world we often have to struggle to convince clients to just do a basic dental cleaning, let alone extra services.  And veterinary practices operate on a pretty slim profit margin, making large capital investments a tough decision.  Thus we end up in the very common situation where an average vet simply can't take true dental x-rays.

My clinic doesn't have dental radiology.  We have a basic x-ray machine, but nothing specific for dentistry.  Yet we do extractions all of the time.  Yes, there is more of a risk of leaving part of a root behind if you don't take x-rays afterwards.  And yes, you may miss teeth that need extracting because you can't see the root and the tooth superficially looks normal.  Do I want a dental x-ray machine?  Definitely!  I think our quality would improve.  But that's a huge expense that we're having some difficulty justifying at this time.  I know that most vets who have already made the decision don't regret it at all, but it's not one we can make lightly.

Our clinic charges around $200 for a basic dental cleaning, with no extras.  Depending on the tooth involved, extractions can run as little as $30, or as much as $150.  That's per tooth!  And it doesn't include antibiotics and pain medications afterwards.  If we have to do multiple extractions it's not uncommon for the final bill to be $400-600.  If we did dental x-rays we'd be adding $100-200 to that bill.  Would the x-rays be better medicine?  Would we increase the quality of our care and improve patient outcome?  Yes to both!  However, it's often a challenge to convince people to even do extractions, let alone any other services.  In fact, nearly half of our clients decline extractions, even though they are medically needed and not doing so can lead to further pain and problems.  Even when they agree it is often a tough decision and we can tell that they're having to figure out how they're going to pay for it.

Really it comes down to finances.  If clients are willing and able to pay for x-rays, and you can do enough of them to cover the cost of the equipment, then it is certainly better medicine.  But if clients won't pay for it you will invest a large amount of money without ever seeing it paid off.  That's not a good business decision.  The harsh reality of veterinary medicine is that we can only do what clients will agree to.  We may know better ways and be able to get better equipment, but then we have to be able to charge for those "betters" so we can pay our bills and stay open.

So what do we do?  How do we still do proper extractions without the x-rays?

Honestly, we just do the best that we can.  All of us know that leaving parts of the root behind can lead to worse problems of infection and inflammation.  However, that doesn't seem to happen in the real world anywhere nearly as much as I hear from the specialists.  We know what to look for and what the root tip looks like.  For all practical purposes we do indeed know when we have all of the root.  There is a very distinctive appearance to the tip that we can easily see.  This doesn't prevent a small sliver from remaining, but when the whole root is out, we know it.  It's the questionable situations that are the concern.  These are the ones where the tip doesn't look quite "right", and we wonder if something was left behind.  In a case like that most of us will go in with instruments and remove as much of the potential retained tip as we reasonably can. 

Now let me circle back to Jennifer's specific situation.  In that case I would agree that post-extraction x-rays are absolutely the best way to go.  However, if a doctor does enough extractions they will have a darn good idea of whether or not they got the whole tooth.  Does this doctor have that kind of experience and judgement?  I honestly don't know, even though Jennifer's description sounds like it might be true.  Personally I wouldn't attempt dental x-rays on an awake pet, because they will move around too much to get good views and it could put the veterinary staff at risk for unnecessary radiation exposure (hands in the x-ray beam to hold the pet and so on).  If you are really concerned, ask her to take proper x-rays, even if you have to pay for them.  Or get a second opinion from a board-certified dental specialist (in the US you can go to the website of the American College of Veterinary Dentistry).

I know that my practice owners are seriously looking at getting dental x-rays in our clinics, and are weighing the costs and benefits of various manufacturers.  I do think that this will allow us to do better medicine and provide a better service, so I'm hoping that this will happen soon.  I'm never opposed to improving our medical quality!  Even though I personally don't like dentistry, I'd be eager for us to have this equipment.

If you have a vet who uses dental x-rays, please be willing to pay for this service.  It really is a good idea and has strong justification in even minor dental issues.  If your vet doesn't have them, don't think less of them because they are still capable of doing a good job with your pet's teeth.