12/19/2002 Entry: "Dental Outlaws?"

Few veterinarians have advanced training and skill in equine dentistry; but many of the people who DO must work outside the law.

By Diana Thompson

Many horse owners work with trusted veterinary professionals to assure their horses receive exemplary health care. Often, they are advised to care for their horses’ teeth by having a procedure commonly called "floating" performed by the veterinarian at least once a year. Once that task is completed, they rest assured, thinking their horses’ teeth have received proper care.

They couldn't be more mistaken. Floating or filing the points of a horse's molars constitutes less than 10 percent of the dental care the typical domestic horse needs. Problems in our horses’ mouths can interfere with digestion, cause colic, create chronic jaw and neck stiffness, and even contribute to lameness. In reality, horses who do not receive complete dental care often suffer unnecessary health and performance problems as well as shortened life spans.

The truth about teeth is that most veterinary practitioners, no matter how highly skilled they may be in other areas, know very little about our horses’ mouths and teeth. Many veterinarians receive less than 10 hours of formal instruction about the equine mouth in school. It is a serious omission in their professional education and a missing piece in equine veterinary service. And unfortunately, only a few veterinarians seem to know how much they don't know!

Dental technicians

One exception is Dr. Richard Miller, a veterinarian whose equine dentistry practice is based in Rancho Santa Margarita, California. Soon after he graduated from Washington State University and began practicing veterinary medicine in 1961, Miller realized that he knew very little about equine teeth.

"All of my early training came from the dental technicians in the area where I lived at the time, in Lexington, Kentucky," Miller says. "Ninety percent of what I have learned since limiting my practice to equine dentistry in 1987 has also come from technicians."

Dental technicians are mostly non-veterinary professionals who make their living performing dental procedures. However, in recent years, there has been a growing number of veterinarians who have pursued advanced education and practice in the field. The equine dental technicians generally learn their trade by attending horse dentistry courses or by working as an apprentice to an established "master technician."

"Equine dentistry, done correctly, is very hard work and truly specialized," Miller says. "You have to learn it, practice it, and have enough humility to recognize the source of the information. There is now a good book, Equine Dentistry, by Baker and Easley, available to interested horsemen. The last definitive veterinary text concerning equine dentistry was written by Merillat nearly 100 years ago. We need to thank the master technicians for preserving this information during the ‘dark years’."

Teeth and the law

But the highly specialized training and skills of gifted non-veterinary dentists are not much appreciated by the law, and these technicians must often work in a contested legal arena. At this time, some state veterinary practice acts give the legal right to perform dentistry only to licensed veterinarians. State veterinary Boards oversee implementation of these rules. The wording varies from state to state as does every veterinary board's influence on interpretation and enforcement.

In most states, it's legal for non-veterinary technicians to work on horses either on their own, or only under the direct supervision of a veterinarian, if they limit their work to simple filing of the horse's molars ("floating") and applying “bit seats”.

The work necessary to truly balance a horse's mouth, however, may include such complex work as equilibration (balancing) of molars, incisor alignment, and/or extractions. These procedures are considered to be advanced dentistry.

The veterinary colleges offer very few courses in equine dentistry; in fact, there is only one semester-length course in equine dentistry offered at one veterinary school in the U.S. According to Williams, "If a veterinarian learns how to float or do any dental procedures, usually he or she learns it from dental technicians."

Miller sees signs that indicate the veterinary community has at least recognized a problem exists. The American Association of Equine Practitioners (AAEP) addressed the issue by forming a dental forum that has made efforts to reach and educate its members.

In many geographic areas, veterinarians and dental technicians work well together. Truly professional dental technicians want veterinarians involved as the primary health care provider. In advance cases, the horse needs sedation for the dental procedures and may need antibiotics or radiographs as a follow-up – and these are strictly veterinary procedures.

"The relationship between the veterinary and dental technician can be a good marriage," Dr. Miller says. "Veterinarians recognize they are not skilled in this area or too busy, so they work with the technician to see that the horses receive proper care."

Knowledge gap

A problem can arise, however, when the local veterinary practitioner is not aware of his gap in knowledge about equine dentistry. Out of sheer overload, this person may fail to either seek further education about dental procedures or refer clients to knowledgeable professionals. Another difficulty arises for horse owners when their veterinary practitioner – for one reason or another – discourages clients from working with trained veterinarians or dental technicians.

In the early 1990s, organized resistance to non-veterinary dental technicians even surfaced at the national level. Many state veterinary boards, influenced by the AAEP, and the larger American Veterinary Medical Association (AVMA), called for increased legal pressure on non-veterinary technicians. In several cases, the boards moved to prosecute dental technicians in court.

More recently, however, a cease-fire of sorts has been called, as more information has been disseminated about the power of advanced dentistry to improve a horse's health – and as veterinarians have been increasingly exposed to clients who demand dental services. Some vets are viewing dentistry as a potentially lucrative specialty – and one that could get them off the hook for middle-of-the-night colic calls! However, just because the veterinarians are paying more attention to dentistry, doesn't mean they are the most qualified or knowledgeable practitioners to perform the procedures.

Qualified practitioners needed

The politics and legal battles accompanying this issue make it difficult for horse owners to do the very best thing for their horses. Horses desperately need more dental care than what is currently provided. While it is estimated there are more than seven million horses in the United States today, there are only several hundred professionals doing this work.

In the past, a number of professional organizations for equine dental technicians have been formed and disbanded, leaving horse owners without a reliable list of available technicians and some information about their qualifications.

However, a very positive change just developed. As of January 2000, members of two groups voted to merge and form a single national organization providing educational standards, testing programs, or codes of conduct for dental technicians. The newly formed International Association of Equine Dentistry is already building links with the AAEP, as well as offering a list of approved dental technicians to horse owners.

Finding help for your horse

However, as in all industries and schools of education, just the fact that a person is "certified" doesn't mean he is, in practice, skilled or even competent. How do you determine whether your veterinarian or dental technician really knows what he or she is doing?

Todd Williams, of Turner Valley, Alberta, has some practical advice. Williams evaluates horses’ mouths and performs dental procedures in Canada. He also teaches equine dentistry and consults with horse owners and veterinarians in Canada and the United States.

Williams readily acknowledges that there are "certified" technicians who might have advanced training but who are not necessarily competent. Damage can be done to an animal by an unqualified or unaware practitioner, regardless of their background. Williams urges horse owners to educate themselves about their animal's mouth and take charge of finding a well-educated dentist who is also a good horseman. "Horse owners are ultimately responsible for their horses," Williams says.

Watch the dentist work

First, he suggests, ask everyone you know with horses if they know of a good dentist. Get as many names as you can, and then contact these people and ask for some references. Ask where they received their training in dentistry, who they learned from, and how long they have been practicing the art. (If their experience is not more than a year, say, you might want to contact the person who taught them, and ask for a reference.)

If at all possible, make an appointment to watch the prospective dentists while they work on someone else's horses, and look for the following signs of competency and safety:

There are very few instances when a competent and aware dentist – or anyone else – has to use force on the tongue. A horse's tongue and the apparatus to which it is attached are very fragile. Pulling on the tongue can cause permanent internal damage. "If you see a dentist or your veterinarian take hold of the horse's tongue and drag it outside of his mouth and up the side of his head, end the session right there and excuse him," Williams says. "If, for some reason, a dentist does need to hold the tongue, he can and should keep it inside of the mouth or lay it gently to the side."

In almost all cases, a device known as a full mouth speculum is used to hold the mouth open during the dental exam and treatment. A poorly trained practitioner may open the horse's mouth too rapidly and keep the mouth forced open too wide for too-long a period of time, and can fracture teeth if a side mouth steel wedge is placed between the teeth improperly.

"The horse should be able to open his mouth beyond where the speculum holds him," Williams says. "Horses need to have the flexibility to move their jaw up and down with the speculum on. The temporomandibular joint (TMJ) can become stressed and painful if the speculum is adjusted too tightly"

Devices known as gags, spools, or wedges should be used sparingly and with caution. Whereas the full-mouth speculum uses the full set of front teeth to keep the mouth open, the gags are usually rounded steel devices which are slid along just one side of the horse's molars to keep the mouth open. These devices exert all of their pressure on a too-limited area.

In order to physically touch and evaluate all the molars in the furthest reaches of a horse's mouth, a dentist must literally place his hand into the horse's mouth, and reach in all the way to his or her elbow. "If they do not place their hands in there and check those teeth, front to back, inside and outside, top and bottom, they did not perform a proper exam," Williams says.

Equine dental instruments should be kept disinfected, clean, and tidy just as you would expect in your personal dentist's office. Typically, during treatment, the instruments will be kept in a stainless steel bucket filled with water and disinfectant.

Above all, the dentist should handle your horse with skill and respect. Never allow someone, no matter well-recommended he came or how difficult she was to make an appointment with, to abuse your horse. "If you are not happy with how your animal is handled, stop the session and seek other professional help," agrees Williams.

Sedation issues

When hiring a non-veterinary dentist, look for one who is associated with a veterinarian who limits his practice to equines. During the more serious procedures, the veterinarian is necessary to monitor the overall health of the horse, administer sedatives and antibiotics, and help with some of the more complicated procedures.

"Dental technicians who do not have a veterinary license should not be giving sedatives, period," Williams asserts. "The first time a horse has his mouth truly evaluated and brought into balance he will almost always need a sedative for the procedures. I've found once a mouth is balanced and the horse only needs routine work such as floating the molars or cutting the canines, only about 20 percent of the horses will need a sedative."

Because Miller is a veterinarian, he chooses t sedate all patients except pregnant mares in order to reduce anxiety and discomfort for the horse.

Motorized equipment such as carbide burrs and diamond discs, in educated hands, can be effective in dental work, but can be misused by over-aggressive or inexperienced dentists. Tools such as power saws and long-handled grinders can be dangerous and should only be used by the most experienced practitioners.

Miller summarizes his advice to horse owners:

Request a thorough manual and visual oral exam at least once a year. Inquire if your veterinarian is skilled in advanced dentistry. Simple floating is not usually adequate. Many horses require extractions or correction of major malocclusions (bite problems), work which requires considerable skill and training.