Dr. Donnell Hansen, veterinary dentist, sits down with Dr. Andy Roark to advise on the case of a 12 year old yorkie with mild kidney disease who may or may not need multiple extractions. Chanel has approximately 30% horizontal bone loss across the maxillary premolars, and the teeth feel stable on palpation. What do we do? Do we pull them? Or do we leave them? How do we decide?
LINKS
Four Legged Tooth Fairy: fourleggedtoothfairy.com/
Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688
WORKSHOP – What Vet Med Can Learn From Improv:
unchartedvet.com/product/what-vet…arn-from-improv/
WORKSHOP – Loading the Bus w/ Dr. Andy Roark & Stephanie Goss:
unchartedvet.com/strategic-planning/
UNCHARTED APRIL CONFERENCE:
unchartedvet.com/uncharted-april-2022/
Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Donnell Hansen, a Minnesota native, and a small group of friends joined together to form the Moxie Center (which was the first hospital to be now known as BluePearl) in Minnesota’s twin cities of Minneapolis/Saint Paul. Although her daily life is spent in specialty care, in 2011, her and her husband, also a veterinarian, opened Rice Creek Animal Hospital which provides a little balance and perspective about life in family practice. In 2019, Donnell developed Four Legged Tooth Fairy, an interactive small group conference center for the veterinary community to enhance their patient health, practice health, and mental health through veterinary dentistry. Dr. Hansen’s special interest in maxillofacial surgery, however the truth is, she loves the whole darn gig… especially when she gets to share the fun of veterinary dentistry with others!
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with my friend, Dr. Donnell Hansen, veterinary dentist. I am asking her about that case. You know the case, the one where you have the little dog on the dental table and you are going, “Ooh, do I take these teeth? Do I leave these teeth? They are right on the line.” And this dog’s had a little bit of renal disease, and it kind of makes me want to hurry up and get this procedure over with.
Dr. Andy Roark:
But I also want to do what’s right by this dog from a dental and health well-being standpoint in his mouth. I don’t know, guys. I’m torn. Do I take it? Do I leave it? How do I know?” Dr. Donnell Hansen weighs in on that question? Let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast. Dr. Donnell Hansen, thanks for being here.
Dr. Donnell Hansen:
Hi, guys.
Dr. Andy Roark:
Oh man. I appreciate you making time because you’re living in the strange virtual school world that I am living in. Your children are in the house, and they never leave.
Dr. Donnell Hansen:
They’re always here.
Dr. Andy Roark:
I know.
Dr. Donnell Hansen:
They’re always around.
Dr. Andy Roark:
I feel that so much. It’s like, I love you, but get out of my bedroom. Get out of my bedroom.
Dr. Donnell Hansen:
You got to go.
Dr. Andy Roark:
Yeah. It’s that. I’m not doing that. Well, thanks for being here. How you been? You’ve been doing okay as we kick off 2022?
Dr. Donnell Hansen:
Don’t you wonder when people ask you that, how have you been, you kind of want to say, “Well, I think I’m fine. I’m miserable, but I’m wonderful all at the same time.” I don’t never know how to answer that question anymore.
Dr. Andy Roark:
In the pandemic world, yeah, I agree. How you are doing? I’m like, what do you want to know when you ask me that? There’s some nuance here to unpack, but yeah, no, I appreciate you being here. You are a board veterinary dentist. You are one of my favorite people to talk to, and you are a regular guest on the program. I am so glad that you took my call, because we’re heading into until health month, which is the thing that a lot of practices do. I’m a big fan of. I got a case for you. You want to help me out?
Dr. Donnell Hansen:
I’m ready. Thanks for having me, Andy. It’s always fun.
Dr. Andy Roark:
I super enjoy it. All right, here’s what we got. I’ve got a 12 year old female Yorkie named Chanel. Chanel, I’m worried… I’m worried Chanel has a little bit of kidney disease, right? Her creatine levels are a little bit elevated, but she seems to be in pretty good health overall, but I have some concerns about prolonged anesthesia time, things like that, just in the back of my mind. I’m in here. I’m getting ready to do this dentistry. We’ll say I am halfway through the dentistry. I have magically paused space and time to ask you this question right here at this moment.
Dr. Andy Roark:
I am looking at… Chanel’s got some dental disease. She has got a furcation and cross, the maxillary pre-molars. She’s got about 30% horizontal bone loss. The teeth are stable. They’re not the wiggly Yorkie teeth where I’m like, “Blink! Oh, look, this one’s out.” It’s not that. They seem pretty solid. But I’m looking at this and this is 100% percent a should I, shouldn’t I, when do I go forward with extraction, and when do I not question.
Dr. Andy Roark:
To make this a little bit more nuanced here, on Chanel’s lower jaw, she’s got about 10% bone loss on that first molar, like the 309, 409 big tooth down there. I’m looking at that as well. I’m kind of like, do I want to get into that mess, because that’s big mess in a little dog’s little jaw. I think my question for you today is, can you help me decide what is best to do and what is best to medically treat and keep an eye on and how much is too much to do in one setting? These are hard questions, I think, a lot of vets have. Donnell, how do you treat that?
Dr. Donnell Hansen:
It kind of cracks me up actually that you bring up Chanel, the 12 year old Yorkie, because literally on like Tuesday of last week, an old friend client, you know how clients become friends over time, showed up to bring the Christmas gift basket of packaged sausage, right? That gift basket we all know about.
Dr. Andy Roark:
Yeah.
Dr. Donnell Hansen:
And her pet’s names are Audrey Hepburn and Halle Berry, two Yorkies that have since passed away, but Chanel fits perfectly for this 12 year old Yorkie of yours.
Dr. Andy Roark:
Oh, I was going to say Coco Chanel was the third one, the one she hasn’t had yet.
Dr. Donnell Hansen:
Yeah, right. It’s coming. It’s coming.
Dr. Andy Roark:
Yeah, exactly. I see your future.
Dr. Donnell Hansen:
It’s a wonderful family. They’ve become friends after a while. Anyways, listen, I totally get this case. I think like radiographs, we kind of joke that extraction should be black or white. This is when you extract. This is when you don’t extract. I think as dentists, sometimes we get a little bit like, “Oh, you got to do it this way.” I sit there on a Thursday looking at the same Yorkie, thinking, “Hmm. Do I have to do this? Do I want to do this? Do I have to pick up my kids at 6:30?”
Dr. Donnell Hansen:
You’re thinking all these things when you’re sitting down to this patient to try and make what’s the right choice. Have you learned Andy, maybe it’s just me, but it feels like there’s no such thing as right and wrong anymore, right?
Dr. Andy Roark:
Oh yeah. It’s all shades of gray.
Dr. Donnell Hansen:
Just a little bit better.
Dr. Andy Roark:
Yeah, no. When I was growing up, there were good guys and bad guys, and good people and bad people, and good decisions and bad decisions. I don’t see a whole lot of those clear lines anymore, unfortunately. It’s all shades of gray.
Dr. Donnell Hansen:
Right. You have to navigate that, especially when you’re doing this and you’re thinking about in the back of your brain… I don’t know about you guys, but I’m always thinking like I’m going to be on A Few Good Men where Tom Cruise is interrogating me. Should you extract this tooth?
Dr. Andy Roark:
You can’t I handle the extractor.
Dr. Donnell Hansen:
I don’t know. I need to rationalize everything. There’s so much that goes into this. Can I ask you? You’re looking at this. You found horizontal bone loss on your x-rays. Did you feel anything while probing? With your little probe when you went along, what did you sense there?
Dr. Andy Roark:
It’s a Yorkie, right? It’s got some gum recession, and it’s got this tiny little mouth. I think that if I want to feel some stuff, then I can feel some stuff. It didn’t drop all the way to the base of the probe or anything. I don’t know if that makes it better or worse, but it’s not like, “Oh, this is a cavern.” If I stuck the probe in there and it was just cavernous space, I would have much stronger feeling about out like yeah. I don’t know if that makes it better or worse.
Dr. Donnell Hansen:
Here’s what you’re doing, right? X-rays will tell you one story, they’ll be one part of the story, and then your oral exam is going to tell the other part of the story. We’re really looking for what is the degree of attachment loss on this tooth, right? And remember, attachment loss is technically your recession. You found recession on this little mouth. You got to add that to your periodontal pockets. Maybe you had three millimeters of recession and you had a three millimeter periodontal pocket.
Dr. Donnell Hansen:
Your brain might just did a little red flag because you think, wait a minute, three millimeters of probing depths can be normal. That’s what we say in the books. One to three millimeters is a normal sulcus. That’s where there’s no attachment loss. It’s just the space between the tooth and the gums, right?
Dr. Andy Roark:
Right.
Dr. Donnell Hansen:
So now we got six, right? And that number is relative. Six millimeters, again, on the Yorkie first premolar is different than six millimeters on a Labrador. Those are two different numbers, and it’s relative the ratio of that dang tooth that you want to think about. The books will say 50% bone loss is where we extract. Have you heard that before?
Dr. Andy Roark:
Yeah.
Dr. Donnell Hansen:
But you guys all know it. At 20%, at 30%, you might have furcation already at 20% on some of these teeth. Because in dogs and cats, their furcation is really coronal compared to what a human tooth might be. You all know what? If furcation is exposed, how many of you guys can floss the tooth of your Yorkie?
Dr. Andy Roark:
Hey, guys. I just want to jump in real quick with a couple announcements over on the Uncharted Veterinary Podcast, which came out yesterday. Stephanie Goss and I are talking about battling negativity in our practices. If you are like, “Eh, people counting down and starting to hear some sort of grumbling and some negativity, and I’d like to handle that in a graceful way and try to help get people back to seeing some of the good stuff that we do,” this episode is for you. I’ll put a link to the Uncharted Podcast down below in the show notes.
Dr. Andy Roark:
Also, in real world things, in person things, the Uncharted Veterinary Conference is coming in April. It is April 21st through the 23rd. It is in person. It is in my hometown, Greenville, South Carolina. Guys, I would love to meet you. I would love to you in person. I would love for you to meet my friends. I would love for you to be part of our community and to get fired up about what you’re doing again, and to see what’s possible, and to see the future as a bright place that can be affected by you. You can take yourself there, and you can take your team there.
Dr. Andy Roark:
You can enjoy and feel excited about what’s coming down the road again. If that sounds good and you’re like, “Man, I’d like to get excited about the future, and I’d like to feel like a lot of things are possible. I’d like to have new friends and see other people who are making their way and who inspire me and who support me and cheer me on and who I can teach and who I can learn from,” then come and check out Uncharted in April. Guys, we are going to have a limited attendance this year just for COVID reasons. I want to keep people safe.
Dr. Andy Roark:
It is a very hands-on active conference, but it’s super special. I mean, ask anybody who’s been to Uncharted. It’s not like anything else. I think most of those people will tell you it’s kind of magic. Anyway, I would love to see you guys there. If you’re not up for traveling to Greenville, and even if you are, other things on the Uncharted side of the house that are virtual, I am working with my wingman Stephanie Goss on some strategic planning courses. On February 23rd, for example, we have a two hour workshop on assessing your employees and loading the bus.
Dr. Andy Roark:
If you are like, “Hmm, I have no idea how I should be evaluating my staff or even what to look for or how to do that. I would like to learn what other people do and how they do that and how I can use those assessments to make my clinic run better and to kind of hold people accountable and things like that,” that’s what this workshop is about. It is from 8:00 PM Eastern to 10:00 PM Eastern on that February 23rd. You can do with math and decide what it is in your time zone, but it’s 8:00 to 10:00 Eastern PM on the East Coast.
Dr. Andy Roark:
Anyway, that’s it. That is the strategic planning, loading the bus. We have another workshop, What vet med can learn from improv, and that’s improv comedy, with Dr. Adam Little. Super fun fundamentals of improv comedy that helps you in practice, as well as life. That is February 17th. That is free to Uncharted members. Guys, that’s enough. We got, like I said, tons of stuff. Head over to unchartedvet.com to learn all about it. I’ll put links to everything in the show notes below. If you are not familiar with Uncharted, check it out.
Dr. Andy Roark:
It’s pretty awesome. I love it. I’m a bit biased. It’s my favorite. It’s my baby. It’s the thing that I work on more than anything else. All right, that’s enough of that. Guys, let’s get back into this episode.
Dr. Andy Roark:
When we’re talking about these really small dogs, does that percent in your mind change based on their size? To your point, 50% loss in a Labrador is still a decent amount of actual not loss. Compared to this tiny Yorkie where you’re talking about, man, 50% is a tiny little bit of bone and tissue. Does the breed make a how difference in this decision if you’re talking about percentage of bone loss?
Dr. Donnell Hansen:
Not really. The reality is as a dentist, we’re probably way more aggressive with the extractions than maybe the average family practitioner would be, which is ironic because my job is to save teeth, right? But really you send us a case and you say, “Oh, these four need to be extracted,” and we end up taking out 12. And that might feel counterintuitive, right? But we recognize that in the vast majority of patients, peridontal disease is not going to get better. We see, okay, it’s a 12 year old Yorkie.”
Dr. Donnell Hansen:
The reason why a breed matters is because it’s a Yorkie, so the propensity for period disease is going to be dramatic, right? Compared to a Labrador. Maybe with a Labrador that was a unique tooth. Something happened to that tooth that caused that one to have more disease than the rest, but you’re not prone to have disease across all the arcades on a Labrador, right? For your case, ooh, 30%, it’s only going to get worse.
Dr. Donnell Hansen:
I’m extracting that one and probably its neighbors, because it’s probably at 20 or 40% or some place in the same neighborhood, right?
Dr. Andy Roark:
Yeah, okay. That makes sense to me.
Dr. Donnell Hansen:
The breed itself doesn’t change my plan. It’s what’s this dog’s risk that changes our plan. And being a Yorkie, the risk is high.
Dr. Andy Roark:
Okay. All right. What other markers are you looking for here as far as how you make this decision?
Dr. Donnell Hansen:
The things that we go through in our heads when we’re thinking about extraction, and right now we have a resident, which is… We’ve always had vets come and shadow us and hang out with us, which is one thing. But now I have a resident who’s shadowing and she’s watching every move, right? I have to rationalize every single extraction or not. If I choose to leave one, I have to have an explanation for that. That makes it harder.
Dr. Andy Roark:
Yeah. It’s just not the gut feel. It’s not the art. I feel this tooth wants to be here.
Dr. Donnell Hansen:
I have to explain myself all the time now. Let’s think about that same Yorkie. If I have a tooth that’s on the fence, now imagine that lower first molar you mentioned, you said there’s 10% bone loss on that lower first molar. Those upper guys, I should clarify, the 30% bone loss on those upper guys, boy, unless I have a very dedicated owner, a family who’s like, “I come every six months. I just adopted this dog.
Dr. Donnell Hansen:
It’s never gotten care before, but now it’s going to get care. That 30% is likely to be stabilized,” I might be convinced on borderline teeth to keep them around with a commitment from the family, right?
Dr. Andy Roark:
Yeah. You’re more trusting than I am. I’m totally going to get onboard now. We’re going to take good care of these teeth starting right now. Okay.
Dr. Donnell Hansen:
I hate to admit, I’m always assessing families, right?
Dr. Andy Roark:
Okay, yeah.
Dr. Donnell Hansen:
I’m quick to say I’m hopefully not judging them, right?
Dr. Andy Roark:
Right. No. No.
Dr. Donnell Hansen:
Listen, my own pets don’t get the same kind of care. That’s my family’s offer.
Dr. Andy Roark:
No. I mean, it makes sense. What I’m hearing from you basically is there’s nuance in this decision of, does this come out or does it not? It’s on the line and some of it is. How vigilant are going to be at home? If this goes south, am I going to get a chance to catch it in a reasonable amount of time? Am I making this decision for the next year, or am I making this decision for the rest of this pet’s life? If it’s the rest of this pet’s life, I may be a bit more heavy handed than if it’s just, hey, I get to look at this in six months or a year.
Dr. Donnell Hansen:
Right. Have they mentioned costs, right? I get it. I can’t always pay for the things that I want to pay for too.
Dr. Andy Roark:
Sure.
Dr. Donnell Hansen:
Have they mentioned it? Have they focused on cost? Have they mentioned time? Maybe they’ve got six kids and taking this Yorkie to the dentist is not going to happen coming in every year. Have they mentioned a fear of anesthesia, right? Some of those families are petrified, and that’s not the kind of family to be saving teeth in.
Dr. Andy Roark:
Yeah, no, that makes less. And when we talked a little bit about this dog’s got a little bit elevated creatinine, how big a deal is that? How big a deal do they perceive that to be? That makes a ton of sense in this decision.
Dr. Donnell Hansen:
Right? Do we expect it to get significantly worse? We can do care on pets with kidney disease all the time. There’s lots of things to do to prevent exacerbation of that kidney stuff with anesthesia and with fluids and with support. It doesn’t stop me in any way, shape, or form. But is it going to halt the family? Is it going to become an issue long-term? Well, then again, I’m more aggressive assuming our current anesthesia is going well, right?
Dr. Andy Roark:
Yeah. Okay. Yeah, that makes sense. Where does this case go bad for me? What are the big mistakes that I need to be watching out for? What are the things you see vets get wrong in this scenario?
Dr. Donnell Hansen:
That’s a hard one, right? I don’t know if there’s really a right or wrong. Here’s the things I’m thinking about. I don’t like to keep a patient under anesthesia if they’re hypotensive, right?
Dr. Andy Roark:
Yep.
Dr. Donnell Hansen:
Bradycardia, we all have come to find ways to manage bradycardia. We know that dexamethasone does that for us. A lot of our anesthetic drugs do that. It’s very rare for me to stop a procedure because of bradycardia, as long as their blood pressures are maintained, right? If I’m debating about a tooth, I’m not…
Dr. Donnell Hansen:
If I have to prioritize a tooth and I have one with endodontic disease, AKA pulp disease, think abscess, and I have one with periodontal disease, think horizontal bone loss or vertical bone loss, if I have to prioritize which one is going to get my priority, the answer’s going to be endo, because that’s the one that’s going to have known pain associated with it.
Dr. Donnell Hansen:
I won’t minimize that perio has pain, so please don’t interpret me as saying that periodontal disease doesn’t have pain. But endodontic disease, AKA abscess teeth, fractured teeth, those guys we know are overtly painful. We all have people in our lives who have periodontal disease and they aren’t wandering around complaining all the time. If I have to pick one, I’m going to pick the fractured tooth.I’m going to clean like heck around the one with perio if I have to get down my procedure now.
Dr. Andy Roark:
Right.
Dr. Donnell Hansen:
Right?
Dr. Andy Roark:
Okay.
Dr. Donnell Hansen:
That one’s going to be my priority. But nonetheless, if we’re having trouble aesthetically, we can stop at any point. We don’t have to proceed. We can regroup and schedule again for two weeks from now to finish the procedure. Make sense?
Dr. Andy Roark:
Yeah, yeah, it does. If I make that call, right? So I say, “I’ve got these concerns. I’m worried about some hypotension, or I’m worried about where we are, or yeah, just financial concerns or whatever,” what are the key things that I need to communicate to the pet owner? What do I need to do going out here? I’ve got some teeth I’ve decided to save, but my expectation is I’m going to get a chance to watch them. How do I set expectations with the pet owner? What are the important parts of that conversation as they leave?
Dr. Donnell Hansen:
The tricky part with what we say to families about we’re going to watch teeth, right?
Dr. Andy Roark:
Yeah.
Dr. Donnell Hansen:
We’re going to watch them. Families assume that means that they can at home assess, “Oh, they’re painful now, or oh, I can watch for swellings or draining tracks or they’ll stop eating,” and they just won’t. If I ever dare to say we’re going to watch something or monitor something and I always clear my notes to say via anesthetized oral exams and dental radiographs. That’s what watching them means. Most times, dear family, you’re not going to know if something’s up.
Dr. Donnell Hansen:
You and I have to have such relationship that you trust me that every year I got to get this patient under anesthesia. Even with the kidney disease, I got to go around and look around in there. And if we can do a yearly care that is an hour long, rather than the three hour adventure of constant extractions, that would be awesome. That’s the goal.
Dr. Andy Roark:
Is that what monitoring kind of looks like in… Monitoring. Is that what ongoing care looks like in your mind is getting the passing back on a regular basis, anesthesia, maybe any grade one cleaning that needs to get done, and then some repeat radiographs? Is that kind of where your head’s at?
Dr. Donnell Hansen:
Here’s the tricky part too, we feel… Maybe I’m projecting, but I think we feel as veterinarians, if we get under anesthesia and we find nothing, we almost feel skivvy be about it like, “Oh, we didn’t need to do this,” right? If it’s beautiful in there, why did I spend their money? Why did I take their time? Why did I take the risk of anesthesia? You guys, the hope is to find nothing. That’s the goal, right? Under anesthesia, clean the teeth, take the x-rays, find out, hey, it’s healthy. I want to find nothing.
Dr. Donnell Hansen:
When I go to the dentist, “Oh, clean bill health. Bye, guys. Thanks. That’s the goal. Don’t feely skivvy about that. That’s preventative care. That’s prophylactic care. That’s the point.
Dr. Andy Roark:
That’s awesome. Donnell, thank you so much for being here. Where can people find you online? Talk to me real quick about the Four Legged Tooth Fairy.
Dr. Donnell Hansen:
Oh heck. Four Legged Tooth Fairy was just a maybe selfish invention for us to be able to offer really, I hope you guys, high quality dental education for the family practitioner. It’s selfish, because then everybody comes to us. We have all the equipment that we need. We got everything that we’ve got in one spot. We all become besties for about three days, and we have so much fun. You have to come to Minnesota. Right now it’s January and I’m wearing my down jacket inside.
Dr. Donnell Hansen:
It’s negative 10 right now inside, and we’re all freezing, but it’s okay. It’s a beautiful place to come. You can embrace the cold. In the summertime it’s gorgeous.
Dr. Andy Roark:
Where can people learn more?
Dr. Donnell Hansen:
Fourleggedtoothfairy.com. Www.Fourleggedtoothfairy.com.
Dr. Andy Roark:
Awesome. Thanks for being here.
Dr. Donnell Hansen:
It’s a side hustle, but we love it.
Dr. Andy Roark:
And that’s what we got for you guys. I hope you enjoyed it. I hope you got something out of it. If you did, as always, the kindest thing you can do is leave me an honest review wherever you get your podcast. I love it. It’s how I get feedback on the show. It means the world to me. I like positive reinforcement. I also love to hear what you guys think we should be talking about and what types of cases you would like to hear. Anyway, that stuff’s always useful to me. Please feel free to let me know. Gang, take care of yourselves. Be well. Talk to you soon. Bye.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
