April 16, 2012
California veterinarians ready to testify against lay dentistry
Scope-of-practice battle wages over teeth cleaning
By: Jennifer Fiala
For The VIN News Service
A battle over the legalization of lay dental care is heating up in the Golden State.
On Tuesday, members of the California Veterinary Medical Association (CVMA) and California Veterinary Medical Board (CVMB) plan to gather in Sacramento to testify against AB 2304. The bill, designed to allow unlicensed animal care workers to use hand scalers to scrape the teeth of pets, is being heard before Assembly Business and Professions Committee.
Organized veterinary medicine is staunchly opposed to non-veterinarians using metal scalers — curved steel picks with sharp points — to scrape hard plaque and tartar from the surface of an animal’s teeth, except when the job is being supervised by a veterinarian.
Their position: Cleaning teeth with such an instrument should require oversight and falls under the scope of veterinary practice. If AB 2304 passes, California could be the only state in the country that expressly takes using a scaler to clean teeth out of the hands of veterinarians.
“We’re doing everything we can to kill this bill,” CVMA Executive Director Valerie Fenstermaker said. “Dogs and cats are being taken into grooming shops where the teeth cleaner sits on the floor and forces the pet's mouth open to scrape their teeth. There’s no inspection for training or cleanliness. If something happens to an animal, there’s no consumer protection. There’s no agency for owners to complain to because these people are unlicensed.”
That’s because it’s unnecessary, say advocates of unlicensed dental cleanings, who liken the risks associated with using a metal scaler to clipping a pet’s toenails. With the use of scaler not expressly mentioned by the California Veterinary Medicine Practice Act — a compilation of laws and regulations governing the practice of veterinary medicine — non-veterinarians have for years used the metal instruments to scrape the teeth of pets without garnering much attention from the CVMB, the regulatory agency that licenses and disciplines veterinarians.
That’s changing with the CVMB's renewed mission to crack down on unlicensed practice.
Canine Care, an anesthesia-free dental cleaning service that operates in more than 600 locations in California, is lobbying for AB 2304 in a battle to stay in business. Owner Cindy Collins — a target in the board's quest to end lay dentistry — did not return a VIN News Service phone call seeking comment, but her lobbyist, Matt Gray, devotes part of his website to the scope-of-practice battle over teeth cleaning. He doubts the veterinary profession’s concerns are entirely medical in nature. Cleaning the teeth of pets is a business, he said, and Canine Care has reaped millions of dollars in profits.
The controversy, he said, is driven by greed.
“What could the VMB possibly be interested in doing that would kill 800 California jobs? This is all about money …” Gray said in a blog he posted on the matter.
Not so, counter CVMB officials. According to the board, cleaning teeth with dental instruments — whether it’s surface cleaning or subgingival work — is the practice of veterinary medicine. Dental cleanings via Canine Care and other unlicensed outfits have proliferated during the past few decades due to a lack of enforcement by the state. That changed in 2010, when the California Department of Consumer Affairs ordered its regulatory agencies — the CVMB included — to tackle unlicensed activity, estimated by government officials to be a $160-billion industry with the potential to harm consumers.
“When the department put the screws to unlicensed activity, Cindy Collins came to the surface,” explained Sue Geranen, CVMB executive officer. “Under current law, what she’s doing is illegal. It’s certainly not personal.”
When alerted to unlicensed activity, the CVMB sends out cease and desist letters and fines those who use dental scalers on animals without a veterinarian’s oversight. Prosecuting unlicensed activity is tough, Geranen acknowledged. While the CVMB is charged with protecting the public, non-veterinarians who dabble in veterinary medicine do not have licenses at risk with state regulators.
"When there's a problem, we often don’t get the complaint because it’s unlicensed activity; people don’t know who to complain to," Geranen said.
Inside the bill, state code and regulations
If AB 2304 is enacted, policing the use of scalers in unlicensed dentistry could become a non-issue. A law granting non-veterinarians the authority to use a scaler without supervision would supercede regulations pertaining to dentistry in the California Veterinary Medicine Practice Act, and take the issue out of the hands of state regulators.
Introduced Feb. 24 by Assembly Member Martin Garrick, AB 2304 amends the term “dental operation” in the state’s Business and Professions Code to allow for the use of “nonmotorized instruments to remove calculus, soft deposits, plaque or stains from an exposed area of a household pet’s tooth above the gum line, provided that service is performed exclusively for cosmetic purposes and the person performing the service first obtains written permission from the person requesting the service.”
The legislation heads off the CVMB’s efforts to add the word “scaler” to the existing definition of “dental operation” in section 2037a of California Code of Regulations. The CVMB’s proposed language change, currently being reviewed by the Office of Administrative Law, specifically defines using dental scalers and scaling teeth as the practice of veterinary medicine.
The language change simply “clarifies” the matter, given that use of a scaler by someone working outside a veterinarian’s office but earning income cleaning teeth already is illegal, the CVMB’s Geranen explained. Unlicensed persons are limited to using cotton swabs, gauze, dental floss, dentifrice or toothbrushes to clean an animal’s teeth, as outlined in the regulation.
When it comes to dental cleanings, the CVMA's stance is that they're "a highly technical and invasive veterinary procedure."
"Nonmotorized instruments such as scalers are sharp instruments and, even with the greatest of care, can lead to painful lacerations in the mouth," CVMA stated its position on the topic.
Despite that warning, Dr. Richard Sullivan, a practitioner in Torrance, Calif., sees many patients in his practice that have their teeth cleaned by groomers.
In addition to harm coming from scalers, he said, it also comes from neglect, when owners mistakenly believe that groomers provide their pets with a thorough oral examination and teeth cleaning services.
“Three weeks ago, I saw a dog that had been to the groomer regularly for teeth cleanings,” Sullivan said. “Of course, the teeth were shiny and white, but the gums were terribly infected. When I opened the dog's lower left eyelid, there was a draining pus. When I opened the lip, the roots of the teeth were totally exposed because of the infection and retraction of the gums.”
The difference between dental care in a veterinary practice versus services provided by non-veterinarians is the difference between prophylactic and cosmetic cleanings. For starters, cleanings outside the purview of veterinarians are anesthesia free, meaning a groomer or other unlicensed animal care worker holds the pet down while using a scaler to scrape plaque and tartar from the surface of teeth.
Inside a veterinary practice, animals are sedated and an oral examination takes place before plaque and tartar is scraped from the teeth, including under the gum line, where disease-causing bacteria can fester. Diseased teeth often are extracted.
“Owners think they’re doing what’s best for their animals by not sedating them, but they’re being sold a bill of goods,” Sullivan said. “They think they’re cleaning their pets’ teeth and it’s safer, especially when these ‘teeth cleaning clinics’ use terms like ‘pet dental hygienists.’”
He added: “The message they imply to consumers is that it’s the very same service but cheaper and better than going to a veterinarian because they’re not using anesthetic.”
Not all veterinarians are opposed to cosmetic cleanings by unlicensed workers. Dr. Rob Lydon, owner of a veterinary practice in Shingleton, Calif., sees nothing wrong with sending pets to Canine Care and other lay dental services for routine cleanings. In fact, he’s outsourced dental cases to Canine Care for at least six years and reports never having a bad experience.
“Anytime you can get a service done without anesthetic, I think it’s a benefit to patients,” Lydon said. “We all know there are risks to anesthesia.”
Lydon considers the debate over lay dentistry to be twofold, the first concern revolving around whether scraping material off the exposed surfaces of teeth is a benefit to pets when non-veterinarians aren’t skilled in identifying true dental disease.
To that, he argues: “This isn’t about deep cleaning under the gums. This is about treating unsightly teeth and bad smells, and there should be a venue for people to do that.”
The other contention, he said, questions whether allowing non-veterinarians to use scalers without DVM oversight harms patients. Nicking the gums with a sharp instrument causes bleeding and brings a potential for infection.
“Sure, a scaler can nick the gum line and draw blood. But the same thing happens when you cut toenails too short, and that can lead to infection and sepsis, too,” Lydon said. “Does that mean we should make toenail trimming go under the purview of veterinarians? Just because there’s potential (for harm) doesn’t mean we should limit this to the practice of veterinarians.“
Lydon surmised that the profession’s turf war over this aspect of dentistry isn’t a high-ranking concern for most of his colleagues.
“What we have here is a lot of complaining by a vocal minority in this profession. The vast majority of veterinarians really don’t care,” he said.
Who's taking notice
That's "absolutely not the case," responded the CVMA's Fenstermaker. In a survey
CVMA conducted last fall that garnered more than 1,600 responses from
veterinarians, anesthesia-free teeth cleaning was identified as the most
prevalent illegal activity in their communities. Two-thirds of the
respondents said they'd treated patients who experienced negative
run-ins with unlicensed workers in dentistry and other areas of
medicine. When asked where they suspected illegal medical care to be
occurring, grooming facilities ranked No. 1. Reports of types of
injuries to patients included untreated dental disease and oral and
facial wounds related to lay dentistry.
"Going to these anesthesia-free dentistry places is like brushing your
teeth twice a day for 20 to 30 years and never seeing a dentist or
hygienist," said Sullivan, the practitioner in Torrance, Calif. "It's
It's also dangerous, said Dr. M. Lynne Kesel, a staff veterinarian with
Laboratory Animal Resources at Colorado State University who, at one
time, taught small animal dentistry. In 2000, Kesel published
"Veterinary Dentistry for the Small Animal Technician."
According to Canine Care's website, Kesel's book is used to supplement a month's worth of hands-on training recommended for company employees. Even so, Kesel does not support the unsupervised use of scalers by non-veterinarians. In an interview with the VIN News Service, she characterized using a scaler to clean teeth as "a surgery."
"It's a procedure that can break the skin," she said. "Any bacteria that
is in an animal's mouth can get in and cause infection. If it’s just
scaling the surface of the teeth and scaling the gums, that’s OK. But
that doesn’t happen. And frankly, you can’t do a good job on a dog’s
mouth unless it’s asleep."
Kesel added that the scaler itself is rough on enamel, which can cause
damage if an animal goes in for a cleaning every month or two as offered
by Canine Care maintenance packages.
"If you don't polish the teeth after, they begin to get rough and
collect calculus at a faster rate," she said. "I would not be scraping
my dog's teeth every month. Essentially, if an animal gets an annual
exam, there might be indications that it needs dental work, but even
that might be unlikely."
Gray, the lobbyist pushing AB 2304 on behalf of Canine Care, said he's
unaware of any consumer complaints involving etched enamel.
“... Cosmetic teeth cleaning is safe for animals and a valued service
for pet owners," Gray wrote in his blog. “This $12-million-per-year
industry has veterinarians licking their chops and doing whatever they
can to mark it as their territory.”
That's what Assembly Business and Professions Committee
members likely will hear from advocates of AB 2304, one of roughly 30
bills on Tuesday's hearing agenda. The CVMA is asking veterinarians to join them at the state capitol in opposition to the measure.
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