Monday Sep 14, 2011
"Why my dog still has bad breath after dental scaling and extraction of 6 teeth?" the lady owner phoned me. She wanted the cause as the dog was done one month ago by Vet 1. She wanted a second opinion by phone.
"It is hard to tell you the cause," I said. "It will be best to examine the dog again."
She brought the dog to me yesterday. "After scaling and extraction, there was less bad breath but now it is bad. What is the cause?"
I asked Mr Goh, a man who came to sell me a new electro-surgical handle to wait. I don't know how the existing handle had lost its protective cover after electro-surgery and I told my assistant that he had to be responsible. He could not give an explanation of how it became lost after electro-surgery done by another vet.
Normally, I take great care of such tools and ensure that the set is accounted for and properly kept. But I did not perform that electro-surgery and that was when the holder cover was lost. It cost me $280 to replace the whole set.
This was a new client who wanted me to give a second opinion. I said: "It is best that I don't just state the possible causes. It is best to practise evidence-based medicine. By that I mean blood tests and a proper examination of the whole mouth for starters. This will require sedation as your dog does not permit mouth opening."
The owner had spent some $260 and said: "The pet shop operator scaled his teeth. I spent money on that. Now, Vet 1 charged me over $200. He is more expensive than (a brand-name vet practice) as that practice charges $10/tooth extracted.
I perused her bill and said: "Vet 1 also charged $10/tooth extracted. $30 for post-dental antibiotics and painkillers. $200 for anaesthetic and dental scaling. The charges are within market rate or lower."
I had the dog weighed and temperature taken. The dog was in good condition. I opened the mouth. The tongue and gums were normal. A bit of tartar and gingivitis. By the 3rd time I opened the mouth, the dog was growling as I tried to view the tonsils.
I put my nose close to the dog's open mouth. The dog exhaled. "Yes, the breath is very smelly." This procedure is actually not good for the vet as bacteria can get into a vet's throat and lungs. But smell is part of practice. The dog did not have such an offensive smell that the small consultation room stank as in some other dogs. Well, he did have dental scaling and 6 teeth extracted and would not be having very bad breath.
"Did Vet 1 do a blood test done before dental work?" I asked.
"He said blood test was not necessary."
"In old dogs, blood tests before surgery is necessary to know the health of the dog before doing anaesthesia. To assess whether the dog will be in danger during anaesthesia and die on the op table. But to save the owner's cost, Vet 1 did not advise it."
I asked: "Did Vet 1 give antibiotics after dental work?"
She said: "Vet 1 said it was not necessary as he had given one injection."
"Each vet has his own judgment as to the management of the case," I advised a blood test to rule out bad kidneys and other poor health as well as bacterial infections or poor immune system. Practising evidence-based medicine is preferred to wild speculations of the causes of bad breath.
"I know Vanessa," the owner had met Dr Vanessa some years ago.
I asked Dr Vanessa to come out from the backroom and both party had a joyous meeting.
"I will ask Dr Vanessa to handle your case," I withdrew from the case. Before I left, I told Dr Vanessa as to what I had said to the owner in the owner's presence to prevent misunderstanding.
I said: "I have advised a blood test and sedation and anaesthesia to examine the mouth properly. The causes can be tonsillar growths, tumours and ulcerations in the mouth and gums due to old age and other causes like uraemic gastritis (hence the blood test). Poor immune system and bacteraemia. So, this was not a simple case.
If anaesthesia is to be used, it is best to give just isoflurane gas. If conservative treatment is wanted, give appropriate antibiotics for 20-30 days.
The owner did not want any more sedation or anaesthesia for the old dog. I withdrew from the case but will follow up.
In conclusion, Vet 1 could have given a week's course of relevant antibiotics post-dental. This would be what I do in my handling of such cases. But each vet will handle a case differently and therefore much depends on the vet's judgment and the outcome. The interesting history from the owner was that this dog has less bad breath after dental work. The bad breath returned soon after. Why? It is like a Sherlock Holmes mystery that needs to be solved and I need to look for Dr Watson to help, assuming I play the role of Sherlock Holmes.
How Mr Goh assess the activity of Toa Payoh Vets? He said he was impressed with my handling of this bad breath case. I don't know whether he was flattering me but we knew each other for over 20 years as he maintained my anaesthetic and medical equipment.
I was surprised when Mr Goh told me the following:
Mr Goh said to me: "Dr Vanessa is very busy nowadays. Every time I visit, she is doing some operations. There are some dogs inside the Surgery and clients outside the reception counter. When she first joined the practice, she was very free."
I said to Mr Goh matter of factly: "We have our quiet days but you are not around." It is possible that Dr Vanessa's clients had re-discovered her after she had left the other practice and so she became busier. There were also my existing clientele. Referrals add up to the caseload and are essential to any veterinary practice.
Mr Goh said: "There is a bad report about a vet in another practice according to the internet research my daughter has done. A dog died after operation and its owner wrote an adverse report about the practice. The owner wrote that when he phoned as to why the dog died, the vet said: "I don't know'. If the vet does not know, why is she a vet?"
I said: "This is where a blood test might be needed and be useful. Evidence-based medicine is important."
It is good to get feedback from outsiders like Mr Goh so as to improve the standard of practice. Younger vets are preferred to older vets as the Generation Y starts working and posseses buying powers. "Old vets are solid," one long-time industry veteran spoke to me once when I told him that there is what I think a trend to prefer younger vets since the new generation has grown up in an era of the internet and abundance. Old foggies should fade away into the sunset?