Supervision of Equine Dental Technicians
Policy type: Position statement
Date ratified: May 2019
The NZVA believes that all dental procedures on horses and all equidae should be performed by veterinarians and be based on sound scientific knowledge, evidence-based medicine and surgery and best- practice standards.
While the NZVA’s position is that all dental procedures should be undertaken by a veterinarian, the Association acknowledges that New Zealand’s current regulatory environment does not preclude equine dental technicians (EDTs) undertaking equine dental work. Accordingly, guidelines have been produced that detail which procedures the NZVA considers appropriate for EDTs and for EDTs working under veterinary supervision to undertake.
In New Zealand there is no regulation of people providing equine dentistry services, except when that person is a veterinarian, who is bound by the Veterinary Council of New Zealand (VCNZ) Code of Professional Conduct. Currently, equine dental procedures can be performed by unregulated EDTs, with varying levels of training and/or experience. There is no governing body in New Zealand that regulates the training, qualification or accreditation of EDTs.
Where equine dental procedures are performed by EDT's in the absence of veterinary supervision the NZVA believes these procedures should be restricted to uncomplicated tooth floating/rasping (NZVA Equine Dental Procedures Category 1).
Where appropriate and presuming the veterinarian is satisfied regarding the competency of an EDT, that EDT may perform other dental procedures, whilst under the direct and continuous supervision of that veterinarian, as outlined in the NZVA Equine Dental Procedures Category 2.
The NZVA recommends that veterinarians follow the guidelines contained in this position statement and in the NZVA Position Statement 10h – Equine Dentistry. Co-operation with competent EDTs is therefore facilitated and encouraged, whilst ensuring the welfare of horses under veterinary care is optimised.
The NZVA’s Equine Dental Procedures Category 2 (see below for explanation) requires the EDT to be under the direct and continuous supervision of a veterinarian. In these situations, the veterinarian is professionally responsible for the dental services provided to the horse. The veterinarian should perform a general physical and oral examination to obtain a thorough understanding of the pathology present and treatment required. If veterinarians lack the necessary knowledge of equine dental disease and the treatment options, a referral is needed to a veterinarian with sufficient training and competency to ensure appropriate procedures are undertaken.
Veterinarians sedating horses for, or working with EDTs undertaking equine dental procedures should be aware of their obligations under the VCNZ Code of Professional Conduct. This includes understanding whether the dental procedure(s) would be considered “significant surgical procedures” as defined in section 16 the Animal Welfare Act 1999 (from May 2020).
It is the responsibility of veterinarians to determine whether an equine dental procedure may be referred, to whom it may be referred and what level of supervision is required (refer NZVA’s Equine Dental Procedures Category List below).
The VCNZ Competency Standards state, “veterinarians must recognise their limitations of knowledge and experience and refer for advice and/or treatment in situations where the animal requires a greater level of knowledge and/or skills.” Therefore, if unwilling or unable to perform equine dental procedures, veterinarians have a professional obligation to “make(s) appropriate referrals” (Section 2, Veterinary Practice, VCNZ Code of Professional Conduct).
This requires that the referring veterinarian is confident that the referral is being made to a veterinarian with sufficient training and competency to ensure appropriate procedures are undertaken. If choosing to work with and supervise an EDT, the veterinarian must be satisfied that the EDT is competent.
In many countries, there are laws prohibiting EDTs from undertaking procedures involving sensitive tissues.
The NZVA recommends veterinarians use the NZVA’s Equine Dental Procedures Category List when determining which procedures are appropriate for an EDT to undertake.
NZVA’s Equine Dental Procedures Category List
Category 1 Procedures
These procedures can be performed by an EDT.
NZVA Equine Dental Procedures Category 1:
- Examination of teeth.
- Removal of sharp enamel points using manual rasps only.
- Removal of small dental overgrowths (maximum 3mm reduction) using manual rasps only.
- Rostral profiling of the first cheek teeth (maximum 3mm reduction), previously termed “bit seat shaping.”
- Removal of digitally extractable (finger loose) deciduous incisors or deciduous cheek teeth (“caps”) that have obvious visual recession of gingival, no periodontal attachments and are protruding above the occlusal surface of adjacent teeth.
No extraction tools of any kind may be used.
- Removal of supra-gingival calculus.
Category 2 Procedures
Veterinarians need to be aware of their professional responsibilities when referring to a veterinarian, and supervising and/or sedating for EDTs for procedures included in Category 2.
Where appropriate and presuming the veterinarian is satisfied regarding the competence of an EDT, the EDT may be delegated to undertake other dental procedures, whilst under the direct and continuous supervision of that veterinarian.
NZVA Equine Dental Procedures Category 2:
- Examination of teeth, evaluation and recording of dental abnormalities.
- Removal of digitally extractable (finger loose) teeth of dental fragments, with NO periodontal attachments.
No extraction tools of any kind should be used.
NOTE: loose teeth often have fractured reserve crown or root portions and the attending veterinarian should investigate this.
- Palliative rasping of fractured and adjacent teeth.
- The use of motorised dental instruments where these are used to reduce dental overgrowths and remove sharp enamel points only (as in Category 1 above, maximum 3mm reductions). Horses should always be sedated when using motorised dental equipment unless it is deemed safe to undertake the proposed procedure without sedation, with informed consent of the owner.
When sedating a patient or authorising the use of restricted, registered veterinary medicines (RVMs) such as sedatives, veterinarians assume a professional, ethical and legal responsibility for the patient, and for the welfare of the patient involved in the authorisation.
Examples of RVMs include acepromazine paste (Sedazine®), detomidine gel (Dormosedan Gel®) and phenylbutazone (“Bute”). Restricted veterinary medicines can only be authorised by a registered veterinarian.
Category 3 Procedures
Category 3 procedures should only be carried out by qualified veterinary surgeons.
All other dental procedures, including the extraction of equine teeth (including wolf teeth), diastemata widening and endodontics meet the criteria for designation as a “significant surgical procedure” and should therefor only be performed by a qualified veterinarian or a veterinary student under the direct supervision of a veterinarian.
Any new procedures which arise as a result of scientific and technical development will fall into Category 3 by default, and are restricted to veterinarians.
Understanding the Guidelines
The routine rasping of equine teeth to remove sharp enamel points and small dental overgrowths has been classed as a Category 1 procedure and does not meet the criteria of a significant surgical procedure. However, veterinarians should be aware there is some difficulty in defining small dental overgrowths. Advances in scientific knowledge of equine dental anatomy including the relation of the dentine to the pulp have revealed that both are sensitive, living structures, and that the pulp may be present only millimetres from the surface of the tooth.
It is now accepted that the removal of dental overgrowths and sharp enamel points, as well as rostral profiling of teeth (bit seats) could potentially expose sensitive dentine or pulp, with serious adverse effects such as pulpitis and death of the tooth. Excessive reduction of dental overgrowths (i.e. hooks, ramps, and excessive transverse ridges) can potentially have an adverse effect on mastication by removing occlusal surface enamel and exposing sensitive dentine and pulp tissue.
Based on this recent scientific evidence, the NZVA’s position is that the reduction of such overgrowths by unsupervised EDTs should be limited to 3mm or less, using manual, non-powered instruments only. Even hand tools with modern carbide steel blades have the potential to remove a considerable amount of dental tissue quickly. Motorised instruments have an even higher risk of removing an excessive amount of dental tissue if used inappropriately, as well as damaging soft tissue and bone.
The guidelines for using motorised instruments for removal of these overgrowths (Category 2) should include frequent water cooling of the affected teeth to prevent thermal damage to the vital pulp tissue. Horses should be sedated when using motorised instruments to prevent the horse from causing injury to itself, the owner or the operator. To manage these risks and welfare issues, the use of motorised dental instruments must be under the direct and continuous supervision of a qualified veterinarian.
The cutting of teeth and all tools associated with such procedures for the purpose of the reduction of the crown height is prohibited. When the tooth is to be extracted, cutting of the tooth is accepted.
Extraction of equine teeth (including wolf teeth) involves the separation of dental tissue from bone by dehiscence of the periodontal ligament, which is a sensitive structure. Tooth extraction is an invasive procedure with serious potential complications and is defined as a “significant surgical procedure” in section 16 of the Welfare Act (from May 2020). It is therefore not suitable for delegation to EDTs. Even extraction of loose teeth can be technically challenging and subject to complications such as subgingival fracture of the tooth and cemental hypoplasia.
The NZVA’s Equine Dental Procedures Category List above only allows for teeth that have advanced periodontal disease and have lost all periodontal ligament attachments, or small tooth fragments with no periodontal attachments that are sufficiently loose to be extracted without the use instruments, to be removed by EDTs. The extraction of all other fractured teeth involves trauma to sensitive soft tissue structures and should be performed only by qualified veterinarians.
In the interests of animal welfare, the removal of wolf teeth (first premolars) requires sedation and analgesia (local infiltrative block). In addition, due to the risk of trauma to adjacent tissues (i.e. bone and the palatine artery) the NZVA’s position is that the removal of wolf teeth should be undertaken by veterinarians.
Tetanus prophylaxis and antibiotic administration should be considered in most cases of tooth extraction.
Orthodontic, Endodontic and Periodontal Disease
The treatment of orthodontic (overbite, under-bite, displaced teeth, bite plates), endodontic (diseased teeth, pulp exposure, infundibular caries and dental tissue irregularities) and periodontal disease (diastemata, gingival inflammation/recession) requires advanced scientific knowledge that only a veterinary education and subsequent equine veterinary dental training can provide.
Under no circumstances should these advanced techniques or the instruments required for these techniques be used by EDTs. The complex surgical nature of these procedures and the use of instruments designed to treat them present a high risk of damage to adjacent teeth and soft tissues, dictating that these procedures should be performed by veterinarians with considerable expertise in equine dentistry (Category 3). Veterinary referral is paramount in cases where these conditions are identified by EDTs.