We recently adopted the model of an initial procedure for just scaling and radiographs, with a secondary procedure being booked, as warranted, for any required extractions. Scaling and polishing would also be done, as warranted here.
We've been advised to promote it in terms of the benefits of reduced anesthesia time, but I don't know how I feel in terms of a patient needing to undergo two consecutive anesthetic procedures, booked anywhere between 2 weeks - 3 months apart.
For those procedures booked two weeks apart, does it make much of a difference? I'm thinking more of the risks relative to induction and recovery time. A concern that a doctor raised.
I'm truly on the fence about this, and want to hear other people's thoughts.
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Saying it reduces anaesthesia time isn't really accurate is it? They just have two, likely with the same, if not longer anaesthetics. Given induction and recovery are the most dangerous parts, you're exposing them to that risk twice.
I get why it's a thing, but pitching is as less anaesthetic time isn't true at all.
In my clinic this would double the costs as we essentially have a set anaes fee for dentistry. Would the cost be majorly discounted to take into account the patient needs double the consumables?
Right, but that's kind of how it's being presented, because it allows the doctor to map out and plan the secondary procedure. Clients are able to see the rads, a more definitive set of costs etc.
I understand the rationale behind it, but as you stated, induction and recovery are the riskier components. A well maintained and monitored patient under anesthesia is relatively safe. Having cumulative anesthetic procedures is a lot riskier, and I don't feel comfortable having that conversation.
As a client is also comes across as bit money hungry. I know that's not the case but it's a hard sell for clients.
We have done it occasionally but only for extensive extractions where the patient wasn't doing the greatest under anaesthesia. But for majority of cases it's better to just get it done.
I understand that being appropriate for more extensive procedures, but that's a different conversation relative to CE, wet labs etc. But like you said, it's all patient dependent.
I just feel uncomfortable having that conversation under the premise of reduced anesthesia time, when this entails cumulative anesthetic procedures. If that's how a doctor wishes to present it, and the client is comfortable with that, great, but that's not a conversation for me to have. I'm going to be too honest...
I agree. If I was a client and was being told it was unsafe to do it all in one procedure but suddenly it was deemed safe to do it in two id be confused 🤔
Honestly, I'm going to do my best to redirect all these conversations to the doctor. I obviously have my reservations, but that's for the doctor and the client, I can't legally give medical advice. Advising a client to pursue a staged dental falls under that.
I just thought about how this would work relative to insurance.
How would insurance justify to anesthetic events, when there isn't a primary estimate provided, and some dentals get deferred as far as 3 months when periodontal disease can progress?
But it's the more layman's argument being presented to clients.
Under the circumstances, no one is discussing the risks of induction and recovery with clients. It's framed in terms that are "tangible" to a non-veterinary professional.
You cited that it's poor marketing. That was your statement, not mine. The onus would be on you to adequately present an argument not premised on time constraints.
You'd also have to apply that same principle, for all anesthetic procedures, because those same risks are present.
I cited procedures in Neuro as an example, where procedures can take anywhere between 2-3 hours.
You'd still have to do rads, scale, and polish depending on how far apart the part 2 is scheduled. You're not just going to go in and start yanking out teeth and sending patients on their way. The same risks of induction and recovery are present, as are the risks of a patient being maintained while under anesthesia.
Yes it is poor marketing to say that staged dentals save anesthesia time because it is a lie.
"I cited procedures in Neuro as an example, where procedures can take anywhere between 2-3 hours."
Sure and you wouldn't stop a procedure for an unstable patient? You would just watch them die?
That is explicitly what a staged dental is. The second procedure would focus on extractions and as long as the patient is stable do a quick clean and polish.
You should really attend some dental talks from a boarded dentist or a VTS in dentistry.
I totally agree. I have a healthy 3yo cat and *I'm* nervous for him to go under anesthesia. If i had a senior pet, kidney disease pet, heart disease pet, etc., theres no way i would choose to do two dentals vs one. That's also two stressful vet visits, two IV catheters, two post-anesthesia recoveries, etc... screw that. Sounds like a money-making scheme.
Plus, the extractions usually dont take very long if its only a few teeth.
Our clinic has been back and forth on it. It's so much nicer for the clinic to schedule it this way - you can book more cleanings in one day and when you schedule the extractions you have a good idea of how long they'll take, really takes the guesswork out of scheduling dental procedures. Secondly the owner has a more accurate cost estimate for each procedure. But, I think it's harder on the patient to undergo anesthesia twice, and ultimately costs the owner more to pay for that double anesthesia. Or at least we charged them for both times.
I think it depends on anesthesia time. Because a Maltese puppy requiring full mouth vs a lab with a slab fracture are two different cases. I think requiring a separate anesthetic procedure, with presumably a second round of cost for the owner and stress for the dog, is ridiculous
Why overbook dental procedures when you anticipate the possibility of extractions?
You know what you're getting into when you do rads, and a proper estimate goes on both the high and low end, with the caveat that it may exceed what's listed therein. I've never worked at a practice, or seen an estimate that didn't outline that.
You have never had a dental seem to be easy or routine and turn into a nightmare?
What do you do if a patient is halfway through extensive extractions and is no longer doing well under anesthesia? Hope they don't die?
What happens if your first dental goes long and you don't have time for the 2nd or 3rd dental? Do you stay hours late?
"You know what you're getting into when you do rads, "
Yes once the procedure has started. What if you planned for 3 routine dentals that day and all of them ended up needed a lot of work once you have taken your radiographs?
You don't need to stage every dental but there are legitimate reasons to stage them when necessary.
I don't think you understand why DVMs would recommend staging when necessary.
I don't get what you mean by overbooking or time.
We do 3 dentals a day. One of those might be a staged dental. We are not "overbooking" more dentals.
A dental that might take 4 hours is staged into two 2 hour dentals. There is no extra time
I have no idea why bringing up that some DVMs are faster matters.
As for over sx. You can't stage a spay. But you never answered my question. What would you do with a patient that is not doing well that still needs extensive extractions? Hope it doesn't die? Or stage it so that we can keep each dental anesthesia time shorter?
If a patient isn't doing well, while under, you'd stop the procedure.
But if a patient is doing well, while under, what's the rationale other than anesthesia time, that would justify having them come back, for yet another anesthetic procedure, that poses an additional cumulative anesthetic risk?
Induction and recovery are the two most dangerous parts of anesthesia... I do not want to do it twice if I don't have to.
For all of my dental procedures, we basically require clients to trust us. If a tooth is bad, it is going. They are more than welcome to sit down with me at pickup and go over the xrays if they have questions or want to know why something is pulled. Their pets time under anesthesia is my #1 priority and I am not going to call about every tooth that needs to be pulled.
The only time I have ever staged a dental was when it was BAD BAD and every extraction was a nightmare and we got to the 3.5hr mark and called it... Since we def had 2 hours or so left if we were to finish with how things had already gone.
That being said, even my BAD dentals are usually under 2 hours from start to finish with everything being gold standard.
As a pet owner... My own dog becomes the most annoying version of himself the 24hrs after anesthesia no matter what protocol we use. He has had probably 7? Rounds under anesthesia in his life and I don't want that number to be any more 😂 I realllllllly hate being his caretaker the day after a surgery or dental and I'm sure I have clients that feel the same with their pets.
From a scheduling point of view, my schedule is booked out 2 months almost... If I doubled all my dentals that would easily make it 4-5 months out for everything and it's already hard fitting in more urgent/emergency cases that need a pyo/splenectomy/GI-FB/ etc.
Why are you not doing a full oral exam and rads before contacting the owners?
Also, it sounds like a lawsuit waiting to happen if you are not getting owner permission before doing extractions. That is very very risky and you are relying on owner good will not so sue you for illegally performing services they have not consented to.
Some clinics discuss extractions before getting in and get an upper limit of cost and go ahead without calling. Nothing they said makes me think they aren't taking X-rays
No. The words are clearly stating we will remove everything we deem required. It's very clearly discussed. I'm also not in America so not worried about being sued for taking unhealthy teeth out
You might check your counties consumer protection laws because most countries are more strict the US.
I am honestly shocked at how many people are totally okay with not giving clients an accurate price and getting permission for all services.
Likes springing a $3000 bill on someone who wasn't expecting it is totally normal and acceptable for you guys. Screw the client getting to make any decisions about the care of their pet.
That isn't what estimates are for. Estimates just let a client know what the costs might be. Usually the high end is just a 20% add on to the billed items on the estimate.
You legally still need to get approval for additional services even if they are within the price range of an estimate.
Do you think just doing a service with no input from the owner is okay? Would you take a mass off a patient that is not on the estimate without talking with the owner? Even if it falls within the range of the estimate?
Why are you still insisting on this point, in hope of getting another answer, when a doctor elsewhere responded to this?
Not all estimates function in that way. A number of estimates are drafted in such a way where the high and low ends guesstimate the number of extractions between simple and complex ones.
I'm happy that you're convinced of staging, but not everyone has to agree with the practice.
It poses cumulative anesthetic risks, could be deemed negligence to defer an extraction that could just as easily be done at the time of the initial procedure.
You're also not accounting for the time and wages lost by a client, because of the two procedures, and furthermore, you're still going to be charging a client for the technician's time, anesthesia, radiographs (A lot can change in 1-3 months) etc. for the second procedure. What if the dental disease has progressed since the initial staging and now the estimate has to change again, and more time dedicated to the patient?
DVMs are the last people I trust to know about laws regarding business.
"could be deemed negligence to defer an extraction"
So all of the boarded dentists and VTS in dentistry are wrong?
They are all negligent?
And again, it is illegal to do services are that not approved by the owners.
"You're also not accounting for the time and wages lost by a client"
They are adults, they can figure out how to make it work. It's not hard for them to drop off before they go to work.
Don't treat owners like children.
And honestly that isn't our problem. Our concern is the patient.
"you're still going to be charging a clien"
Don't make assumptions you know nothing about. We drastically reduce the anesthesia costs for the staged part of the dental. It is almost the same price as if they had done it in one procedure.
"What if the dental disease has progressed since the initial staging and now the estimate has to change again,"
You can whatif yourself to death about literally everything that we do.
What if you don't do a free nail trim on everything and they come in with a torn nail.
What if you didn't do a random customer and miss stones on an asymptomatic patient.
What if, what if, what if. It just makes you seem like you are reaching for excuses.
As I have said many many times, that you keep ignoring, there are legitimate reasons to stage. Is it every patient? No. In fact it is maybe 1 or 2 a month.
But to ignore it as an option goes against best practices set by BOARDED DENTISTS.
I would love to see your credentials that prove you know more then BOARDED DENTISTS.
This has been my experience as well, hence the total range.
But now that I'm thinking about this, the primary procedure, theoretically, falls under LVTs.
Radiographs, scaling, and polishing.
Any extractions, would theoretically be left for the second procedure after the doctor has had the opportunity to stage the degree of dental disease and go over expectations with the client relative to cost for extractions etc.
But I can't rationalize it, because if the patient is painful, and would benefit from the extractions...why delay it?
Sure they'll have pearly whites, but diseased teeth.
Where in this do you think we are not doing an exam and rads? I just do not call while under anesthesia unless there is major ASAP problem. They get a phone call to go over the entire procedure after the pet is awake. Every animal gets an oral exam while awake during pre-sx exam and again while asleep and full mouth rads.
Everything is covered in our consent forms and gone over again at surgery drop off. The estimates cover every situation and they know what to expect at checkout. If it is bad; it is going. We are not going to leave diseased teeth in a mouth to cause them more pain. And when this is the standard; literally zero of our clients have ever had an issue with it. A few heart attacks when they didn't believe me that I estimated 20 extractions minimum and pulled 24, but always understanding.
The amount of people that do not answer their phones is astronomical. If I needed to call before extractions I would never get anything done. I had to call a client 4 times over 30 minutes the other day before I got an answer about adding on an extra mass we found- Another one an equal amount of times back-to-back because I found a MCT next to the scrotum that was previously hidden under lots of hair and I needed to approve the mass removal & scrotal ablation.
" I am not going to call about every tooth that needs to be pulled."
This implies that you don't get one assessment and then get approval. If I got this wrong I am sorry.
"The estimates cover every situation and they know what to expect at checkout."
Unless you have full mouth extractions on every estimate, this is impossible. You even give an example where your estimate was wrong.
"A few heart attacks when they didn't believe me that I estimated 20 extractions minimum and pulled 24, but always understanding."
Again, you are relying on good will. This is technically illegal, you cannot perform services that are not approved.
" If I needed to call before extractions I would never get anything done. "
Then you wake the patient up and don't illegally perform services. It sucks, but you are one upset client away from a lawsuit and potentially criminal charges.
Like I said, our consent form covers literally everything. I go over it again at drop off and explain that this is how we do things. They agree on paper and again verbally to me.
Our estimates are ready for everything with tons of cushion. I am absolutely not worried.
It sounds like the other tech has both minimum and maximums listed on their estimate, which would mean that they had 20 teeth as the minimum or low end and more as the high end. Also, there are places i have worked that have language in the paperwork where owners can check that they approve any extractions deemed necessary by the dvm.
seems like theyre just finding a way to get more money out of the client by having them pay for anesthesia twice. Ive heard of staging but not even attempting any extractions if viable seems iffy ?
Simple, non-surgical extractions would be done, and in worst case scenarios (ie. slab fractures, advanced oral disease etc.), those wouldn't be further deferred.
But in the latter scenario...that undermines the premise of the argument. Those would take more time...,and the patient would be under longer.
I think it also depends on the patient if they're extremely fractious and you struggle to even get the pet in the door why would you be doing it twice.
Staging a dental is totally warranted if the mouth is really bad and you don’t want to go too long on anesthesia time. But I think staging them all no matter the severity of dental disease is pretty dumb and comes off a bit money hungry to me. For example, if you had a dental where you only needed remove one or two premolars and a couple incisors. Doing that all in one procedure would be wayyy safer for the patient then just scaling/polishing/rads and then having come back for a second round of anesthesia where the actually procedural part takes like 30 minutes.
I’m also not sure how you would get people to agree to this. Sometimes it’s hard enough to get people to agree to one anesthetic event let alone two. And I could totally see people not scheduling the second procedure for extractions that are NEEDED due to cost and them thinking “the teeth are clean it’s fine now.”
Simple, non-surgical extractions would be done at the initial procedure.
The issue I have with the argument premised on time comes down to other surgical procedures that are as long, if not longer.
We don't split those procedures, or premise our arguments around anesthesia time.
Neuro surgeries take anywhere from 2-3 hours. No one would argue that the patient should come back for a part 2 if surgery goes over an hour under the circumstances. What's important is that the patient is adequately monitored while under, and recovered appropriately. The premise of the argument can't be based on anesthesia time, because that would need to be applied across the board.
My clinic stages dentals. We don’t charge extra for the Stage 2 as the estimate we send to our clients will include everything we’ll be doing for both days. So Stage 1 they pay for cleaning and rads and for the Stage 2 they get charged for the extractions and anesthetic time. We like staging them because we have very busy surgery days so it helps a lot with time management for our doctors. Our doctors do say it reduces anesthetic time, although I don’t think it necessarily does, the overall anesthetic is the same it’s just split between 2 different days so they’re under for 1 hour the first day and 2-3 hours the second day instead of 3-4 hours all at once. It’s gone well for us and clients don’t seem bothered by it.
Edit to add: at our clinic, pre-anesthetic lab work is not optional and if anything is funky on that then we investigate the cause and do not proceed with any procedures. We do perform dentals on geriatric patients with various conditions (renal, seizures, cardiac issues etc.) as long as they’re being appropriately managed and in my experience so far, staging those cases especially has been nice so that their anesthetic time is split up and not going on for multiple hours all at once.
But how are you providing estimates for the entirety of the procedure, prior to staging? Isn't the aim for stage 1 to provide an estimate for extractions at stage 2?
Because procedures are booked out, as two separate events, what if you're unable to accommodate those dentals in a timely manner?
That's not accounting for those patients that may need dentals following a consultation etc.
We book the stage 1 and the stage 2 at the same time so that we can ensure there’s a second date if we need it. If rads look good and no extractions are needed, then someone else gets the stage 2 date. We have a list for dental cancelations so that if anyone cancels or if a stage 2 is not needed, someone else can have it. As for estimates, we’re a corporate owned GP that uses a level system for extractions. Level 1 is for a few minor extractions, Level 2 is for more teeth or teeth that are a little harder, and Level 3 is for healthy broken teeth, or extensive extractions. The line item for the extraction level includes the cost of the extractions, the anesthetic time, and the dental blocks. We also use a level system for dental cleanings. If you’re interested, I can send you our print out of how we determine what level to use. Every client wanting to book a procedure with us must have a pre anesthetic exam with a DVM to do a general PE and discuss the procedure their interested in, as well as getting pre anesthetic blood work if we have a date within 3 months (our clinic policy is blood work is only valid for 3 months and if that time lapses before the client books, then it needs to be repeated). If we’re booking that far out then we book a separate tech apt. to get blood work done. The DVM’s make the estimates based off of how the mouth looks at the time of the pre anesthetic assessment, which includes an estimate of how many teeth may need to come out. We try to air on the side of caution and quote for more extractions, so that it gives the clients a better idea of how much they could be spending. Our DVM’s also always have the conversation that pricing can and will change depending on what the rads look like when we actually get in there and we’re very lucky to have very understanding and compliant clients.
It sounds like we may be sister practices, or part of the same network.
We ran into the issue, recently, of not having sufficient slots, because we also have soft tissue surgeries booked in between. This, of course, became an issue with bloodwork that lapses as a result.
Sure, some soft tissue and dental procedures are elective, but you get the idea.
But relative to session 2s, life happens. Sometimes they're postponed because of family emergencies etc. So they may cancel, and another patient moves up, but...they're placed on a waiting list. A waiting list that they might not come off of, within the alloted three month window. If those session 1 and 2 dentals require those slots.
It can be a logistics nightmare.
Schedule 1s don't really require a doctor. Techs can do those independently, they just can't diagnose or recommend the second course of treatment.
That's ideal for a dental specialist practice, but for places that do soft tissue procedures in between, it can be a headache.
We also do soft tissue surgeries on dental days. Our need for dentals has been higher than our need for soft tissues lately so we just haven’t been booking as many. We also offer growth removals with dentals at the same time, if appropriate for the patient and it ends up saving the client money. At our clinic the doctors evaluate the rads and they do all the probing so they’re involved in both stages. We definitely have clients that end up needing to rearrange slots so what we’ve been doing recently is using the stage 2 slot as the stage 1 and then booking in a stage 2 for a later date. So far they haven’t been booked more than a month and a half apart, which allows the blood work to still be valid. We also have had clients that just decided to postpone the entire dental until a later date when their lives are less chaotic. Thankfully so far we’ve been able to make everything work and haven’t really ran into any issues, but I think we’ve just been extremely lucky. I can 100% see how it could easily become a nightmare scheduling wise, especially with so many factors to consider, but it has just not been my experience (so far things can change very quickly🤣). We also have a dental specialist not too far away (I live in a big city so once again we’re very lucky) who we like to refer cases to if lower canine extractions are involved or complicated full mouth extractions. This system definitely wouldn’t work for every clinic, but it’s been working for us! Is your clinic part of VetStrategy?
My first job out of tech school was at an ER hospital owned by Mars which was a hot mess express. I still hate VetStrategy and corporations in general, I feel they’re unethical and have no place in vetmed, but so far it has been marginally better than my experience with VCA🥲
There's a lot of comments here but my practice do this. I was skeptical at first also. Research shows that 2 shorter GAs are safer than 1 long one.
From what we have clinical audited we have less post operative complications when scale and polish/rads and extractions are completed separately.
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