Treatment

Many of the procedures described in this chapter can be carried out by dental technicians, suitably experienced clinicians and suitably qualified or experienced animal health professionals, and with limited resources. However, some of the dental procedures may be more complex and may need expensive equipment, such as dental extractions, management of diastemata and periodontal, or sinus interventions, and may need to be carried out by experienced clinicians in well resourced hospitals or field situations. This should always be considered when deciding on treatment and producing a treatment plan.

TREATMENT PROTOCOLS

Treatment protocols to be followed will depend on several factors. The age and condition of the donkey, any underlying conditions that may dictate treatment, and the situation and availability of resources such as equipment and expertise will always need to be considered.

It may be that in some situations treatment is not possible and conservative methods of managing the disorder must be followed in line with requirements for animal welfare.

The following protocols are guidelines only.

Regular prophylactic dental treatments

These are often carried out in the standing and unsedated patient by a vet or a dental technician. Vets and dental technicians carrying out the treatments should share information where required, and ensure that the owner understands any conditions or requirements for additional care.

Procedures should include:

• assessment of the body condition score, diet and general health

• assessment of the dental function

• recording and charting dental health and creating an ongoing plan with re-examination dates.

Advanced dental treatments

These are often carried out in the sedated patient and may require anaesthesia. In most countries, advanced dental treatment will be performed by a veterinary surgeon with experience of equine dentistry, but this resource may not be available globally. Additional safeguards are needed when dealing with donkeys because:

• the dental disease may be advanced

• there may be underlying health issues

• the behavioural signs associated with ill health are subtle

• the patient will often be geriatric.

Before the use of sedation or anaesthesia it is always best practice to perform a full clinical examination for any undetected conditions or complications, taking baseline haematology and biochemistry where necessary and checking for triglycerides (to assess appetite) and liver disease/hypoproteinaemia (common in aged animals).

Ensure the owners are aware of any implications for aftercare, possible complications and cost, and obtain consent if off-label drugs are to be used. Assess the current diet and the need for any dietary modification after the procedure, as it may be necessary to start to introduce any diet modifications before the dentistry is performed. Plan for the donkey's companion to accompany the patient and be nearby during the procedures and aftercare to minimise stress.

The following guidelines are advised for the advanced procedures:

• The use of an intravenous catheter is advisable for long procedures because intravenous injection can be challenging in a donkey and frequent top-ups are often necessary.

• Avoid extractions on both sides of the mouth on the same day.

• Plan multiple extractions in stages and ensure excellent post- procedural care including analgesia.

• Monitor appetite carefully post procedure. Intervene early with nutritional support if the donkey’s appetite is reduced.

• Pain score the donkey regularly during and post procedure and adjust analgesia accordingly.

Dental treatment in compromised patients

Dental disease is a contributory factor in many clinical conditions including choke, colic, weight loss, anorexia, hyperlipaemia, and nasal discharge. Treatment of the dental conditions may need to be delayed until the donkey is able to cope with the stress of treatment. In such cases the recommended course of action would be to:

• treat the primary condition

• obtain baseline blood samples

• provide sufficient analgesia to enable the donkey to cope with the dental disorder

• ensure the diet is suitable for the dental condition and the primary condition

• plan a date to start necessary dental treatment when the donkey has recovered sufficiently from the secondary condition to be able to withstand further intervention.

Dental treatment for geriatric donkeys

Many elderly donkeys have severely neglected mouths and accompanying health issues. It is essential to assess the health of the donkey, including the quality of life, and to follow a detailed treatment plan for any dental disorders. The recommended course of action is to:

• Perform a full clinical examination and take blood samples.

• Consider regular quality of life assessments to monitor changes to the health and welfare of the donkey.

• Aim for a pain free mouth.

• Change the diet to one that is appropriate to the dentition.

Interdental plates usually cause severe trauma. If the donkey presents with complete edentulism (toothlessness) of the incisors, it is preferential to use ground out incisor plates (with or without a dressing material shield), on the speculum and not 'gum bars' placed in the interdental space.
If the incisors are loose, they should be extracted.

It is not uncommon in elderly donkeys with extensive periodontal disease, particularly on the maxillary arcades, that once one tooth is extracted, two or three others lose their stability and also require extraction. Consideration should be given beforehand and a clinician consulted so that radiographs can be taken if necessary in order to assess the likelihood of multiple extractions so that adequate time and drug therapy may be employed.

TREATMENT PLAN

A detailed treatment plan is advisable where any treatment or correction is necessary. This will allow for consideration of the health, quality of life and aftercare of the patient.

Staged treatment respects the anatomy and physiology of hypsodont dentition and is essential to be able to manage pain, reduce stress and ensure appetite and access to adequate nutrition.

A treatment plan will help to manage owner expectations, making them aware of any additional care that will be necessary, implications and costs.

When producing a treatment plan it is important to consider the following factors:

• Asses the general health of the donkey before treatment, a full clinical examination is advisable in all cases.

• The quality of life of the donkey and the benefits of treatment need to be balanced against the procedures necessary for treatment and the effect of these procedures on the well-being of the donkey.

• Consider the resources available, including drugs, experienced personnel and environment for aftercare.

• Any suddenly reduced function, in addition to stress, possible pain and potential infection which may cause acute inappetence and risks the rapid-onset of hyperlipaemia.

• Extractions should always be staged if the affected teeth are on contra-lateral arcades, as it is beneficial to leave the donkey with one pain-free side on which to eat.

• Conservative procedures scheduled at regular intervals are preferable to one curative treatment, especially in cases of acute/chronic anorexia, dysprehension/dysmastication, colic and hyperlipaemia where treatment, stress and post-procedural discomfort may adversely affect recovery.

• Pain assessment is a very important part of the treatment plan and it is a legal and ethical requirement that pain is adequately managed.

• Dietary management must be a part of the treatment plan. It is usual for cases suffering multiple oligodontia/exodontia to require modification of the diet to provide adequate nutrition while minimising any risk of choke, colic and hyperlipaemia. Dietary changes need to be made gradually and well in advance of dental treatment.

• Consider the location of the donkey and its comfort during any procedures; for example, a foot sore donkey should not be made to stand on bare concrete for long procedures.

SEDATION AND ANAESTHESIA

Dental procedures are often performed in the standing sedated patient and nerve blocks are commonly used. Effective local analgesia will enable a reduction in the requirements for sedation and analgesia.

Where the treatment may be of a prolonged duration it is best practice to use intravenous catheterisation.

It is important to check dosage and rate of dosing for the donkey before the procedure, and also to obtain an accurate weight for the donkey.

Accurate weight estimation is necessary for calculating anaesthetic drug dosages. Outside of a hospital situation scales are unlikely to be available.

Horse and pony weigh tapes are not suitable for donkeys and a donkey- specific weigh tape or The Donkey Sanctuary nomogram should be used.

Nerve blocks are placed using aseptic techniques and if necessary after the donkey has been given sedation to ensure accurate needle placement.

The ophthalmic, maxillary and mandibular branches of the trigeminal nerve may be anaesthetised at accessible foramen using the four most common blocks: maxillary, infraorbital, mandibular and mental.

Typical complications arising from the use of nerve blocks include:

• unsuccessful anaesthesia

• puncture of arteries/blood vessels

• inadvertent anaesthesia of the optic nerve/oculomotor musculature

• temporary/extended paralysis of the facial nerve

• neuritis (chronic/permanent).

POST-TREATMENT MONITORING AND CARE

It is essential to monitor the appetite of the patient following any dental procedure.

Early intervention with nutritional support will be necessary if the donkey’s appetite is reduced.

Special instructions for care professionals or owners are:

• Do not feed until any nerve blocks have worn off to reduce the risk of the animal biting its tongue.

• Feed as directed noting any difficulties eating; soft feed may be needed.

• Mastication reduces particle size of long fibre to less than 2mm so feed is likely to become lodged in an open socket. This is why most contemporary surgeons use dressing material/wax to prevent feed stasis, although this isn’t always possible (incisor sockets for example).

• Following extractions, the sockets will need flushing daily if they haven’t been plugged. For example, incisors and wolf teeth.

• A detailed oral examination is required sooner than pre-scheduled if there are concerns about pain, smell or swelling.

Monitoring for pain is essential. Pulse, respiratory rate, demeanour and appetite are good indicators.

Studies are ongoing for ‘measurement of the pain grimace’ as an indicator of pain in the donkey. Results will available at www.thedonkeysanctuary.org. uk/for-professionals when they are published.