"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.
P.S.
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." I
don't know what happened and was just speculating.
Maybe, the blood test had been taken by this vet and was
normal.
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 possesses 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 and have a
different mindset and lifestyle. Old fogies should fade
away into the sunset?
TOA
PAYOH VETS
