Editor’s note: This originally appeared in Equine Veterinary Education, American Edition, Vol. 22, Numbers 1 & 2. Reprinted with permission of the American Association of Equine Practitioners.
For the past decade the practice of equine dentistry in North America, as well as other veterinary services such as reproductive services, chiropractics, physical therapy/rehabilitation, acupuncture, prescription drug sales and complementary medicine, has been the subject of increasingly heated political debates and legal actions. Unlicensed dental care providers are demanding the right to autonomously provide veterinary services without professional education and accountability.
Most equine veterinarians are aware of the recent legal cases involving the practice of equine dentistry in Minnesota and Oklahoma as well as an ongoing case in Texas. However, the January 2009 decision of the Appellate Division of New York State Supreme Court to reject the state Racing and Wagering Board’s appeal to keep an unlicensed tooth-floater from working on horses demonstrated the ultimate consequence of the deregulation of equine dentistry. Consequently, the court found that veterinary dentistry in all species is excluded from the practice of veterinary medicine.
Equine dentistry today
It is fair to say that many people within the horse industry, as well as within the veterinary profession, are confused about the current standards of equine dental care and who the proper providers of this care should be. Many horse owners and veterinarians perceive that equine dentistry is nothing more than benignly rasping the points off of a horse’s teeth and that the practice of equine dentistry falls below the professional practice of veterinary medicine.
However, equine dentistry is not, and never has been, synonymous with floating teeth. Dental practice includes the evaluation, diagnosis, prevention and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures as well as the evaluation of the contribution of oral conditions to the overall health of the individual patient. Dental practice is provided by a veterinarian, within the scope of his or her education, training and experience, in accordance with the ethics of the profession and applicable law.
Oral conditions can be the cause of systemic disease such as bacterial endocarditis caused by periodontal disease as well as an indicator of systemic disease such as renal failure or hyperparathyroidism. To practice within the current standard of veterinary care, sedation is required for thorough examination of the oral cavity. Additionally, the diagnostic evaluation of orofacial tissues necessitates the use of imaging modalities, such as radiography or computed tomography. Most dental procedures, including basic tooth floating, are irreversible with potentially significant iatrogenic consequences.
Based on veterinary research and the application of dental science, dental practice has advanced significantly over the past decade. We now know that many aggressive dental practices performed during the past half century such as severe “bit seating” and “performance floating,” are either unnecessary or detrimental. The treatment of many dental conditions requires the management of pain, inflammation and infection, and possibly the treatment of concurrent systemic disease. Veterinary training is a prerequisite to the practice of equine dentistry within the current standard of veterinary care, and the practice of equine dentistry by autonomous non-veterinarian dental care providers (NVDCPs) jeopardizes the health and welfare of horses.
The risks of non-veterinary dental care providers
While a few states allow limited dental services to be provided by the employees of veterinarians or by licensed tooth-floaters, autonomous, unlicensed NVDCPs are providing equine dental services ranging from floating sharp enamel points to major dental surgery throughout North America. Most NVDCPs begin their practice with good intentions, ignorant of veterinary practice regulation; however, except for a handful of individuals in certain states, all are fraudulently practicing veterinary medicine without a license and none have the veterinary training or resources to properly diagnose and treat dental conditions. These NVDCPs claim certifications and professional titles, such as “Certified Equine Dentist” or “Equine Dental Technician,” based on completion of non-AVMA sanctioned “dental schools,” which include the Academy of Equine Dentistry, the American School of Equine Dentistry and the Texas Institute of Equine Dentistry or membership in non-professional associations such as the National Association of Equine Dentistry (NAED) and the International Association of Equine Dentistry (IAED). Through aggressive marketing, NVDCPs have created the public perception of professional competency and have convinced numerous equine health care decision-makers, including some veterinarians, that NVDCPs provide superior dental services as compared to licensed veterinarians.
While NVDCPs advertise their superior health care services to the public, their political and legal challenges attempting to exempt equine dentistry from veterinary practice are based on the NVDCP’s “right to work” and allegations that the veterinary profession is trying to create a monopoly. These arguments are based on economics and not health care. If NVDCPs desired a legitimate health care solution to this issue, they would seek a position within the veterinary profession. Legal testimony given by NVDCPs clearly establishes that they admit to breaking state laws, that they have no desire to pursue professional education, and that the majority of NVDCPs do not have, nor do they desire to have, a professional relationship with veterinarians. Veterinarians who work with NVDCPs are encouraged to review the legalities and liabilities of this relationship. Testimony also establishes that the referral of equine patients by NVDCPs to a veterinarian is rare, even in cases where veterinary care is clearly indicated. While NVDCPs claim to be providing a vital health care service to the horse industry, their lack of professional oversight places horses at increased risk of undiagnosed or misdiagnosed dental and systemic conditions as well as inappropriate treatments.
Health care solution — education
Ultimately, the only way to protect horses and to ensure that horses receive proper dental health care is through education. Since health care issues are complex, health care education takes time and veterinarians must be proactive and persistent about the delivery of this education. Veterinarians must educate everyone involved in making equine health care decisions or the practice of equine dentistry will continue to be systematically challenged in every state in North America. Included in the list of equine health care decision-makers are state legislators, state BVMEs, state VMAs, veterinarians, trainers and horse owners.
The practice of veterinary medicine is regulated at the state level. State legislators define the scope of veterinary practice for each state and therefore determine if equine dentistry is included within or exempt from the Veterinary Practice Act. Since state legislators ultimately decide who can legally practice veterinary dentistry, these representatives must be educated about the practice of dentistry before they are asked to make a legislative decision. Public officials should be reminded that the veterinary profession is the advocate for and the authority on animal health care and welfare issues, and appropriate proactive education could prevent an uneducated legislator from siding with a vocal minority to end a public dispute. These representatives are primarily concerned with public (human) health, safety and welfare and with the economic protection of animal industries. Discussions with this group of decision-makers should focus on the consequences of unregulated veterinary practice on voting constituents. Common practices by NVDCPs that threaten the safety and welfare of both humans and horses include the illegal use of sedatives and other prescription medications and having horse owners participate in dental procedures by giving injections, restraining the horse or assisting in dental extractions.
Without regulatory oversight, horse owning consumers are unprotected from the unscrupulous practices of NVDCPs who fraudulently misrepresent their professional education, credentials, competency and accountability (liability). Also, the autonomous practice of NVDCPs puts the horse industry at an increased risk of the misdiagnosis of zoonotic and reportable animal diseases. The education of state legislators is best performed by the state veterinary medical association (VMA).
The state VMA is the organization that represents the interests of veterinarians within each state and is the organization that politicians and the media will turn to for “the official opinion” of the veterinary profession. The state VMA proposes legislative and regulatory changes to reflect the advancing practices of veterinary medicine and monitors legislative bills that could impact the veterinary profession. The veterinary profession is extremely diverse and each state VMA should reflect that diversity. If the state VMA does not have equine veterinarians in leadership positions, uninformed veterinary decision-makers could allow, and in some states historically have allowed, exemption of equine practices from the VPA. Equine practitioners commonly complain that their state VMAs do not represent them; however, in many states the equine and large animal membership of the state VMA is minimal. With the current abundance of large animal political issues, most state VMAs are actively looking for large animal practitioners for guidance and leadership. Equine practitioners must become more involved in and educate their VMAs about the present healthcare standards in equine practice or be content with veterinary representation by uninformed decision-makers.
The state Board of Veterinary Medical Examiners (BVME) is the appropriate authority to hear complaints on illegal or unethical veterinary practices. This board is given legislative authority to regulate the practice of veterinary medicine. Since the BVME comprises gubernatorial appointees, all of whom are not veterinarians, it is unrealistic to believe that each board member is well informed about all aspects of veterinary practice. Equine veterinarians must ensure that the BVME is educated so that they can write regulations that protect horses and horse owners from unlicensed NVDCPs, as well as accurately reflect the current standards of veterinary care. Writing enforceable regulations cannot be performed without the assistance of veterinarians who have expertise in the specific practice being regulated as well as experience with political and legal processes. Again, the education of the BVME is usually best performed by the state VMA.
The BVME’s authority to enforce the VPA varies greatly among states. In most states, the enforcement of the VPA is limited to violations reported to the BVME in formal complaints. Some BVMEs have the authority to prosecute violations filed by any complainant observing an illegal act while other BVMEs are limited to strict consumer protection where the complainant must be the horse owner. In some states the BVME is only allowed to regulate the practices of licensed veterinarians, while a few states deputize the BVME, giving them the authority to prosecute violations of the VPA without a complaint.
While many veterinarians are vocally frustrated by the practices of NVDCPs, few have educated their clients about the appropriate legal actions to prosecute NVDCPs. Still fewer veterinarians are willing to file complaints against the unethical members of our profession who are illegally supporting the NVDCPs by supplying them with prescription drugs and referrals. Controlling unethical veterinarians would significantly reduce the service capabilities of NVDCPs, and this legal action would not result in a costly political debate. While the education of state level decision-makers will improve the regulation of equine dental practice, equine veterinarians must also educate the other members of our profession.
Historically, veterinary practices have been deregulated by forfeit because of the opinions and influence of veterinarians who do not provide that specific service. Most AAEP members consider continuing education a vital part of practice; however, non-member equine veterinarians, as well as veterinarians who work with other species, may not be aware of the current dental care standards and issues. These veterinarians may also influence decision-makers within the veterinary profession and horse industry. Practitioners who limit their practice to dentistry need to keep their colleagues abreast of the advances in dental science so that equine veterinarians can then in turn educate other members of our profession. All veterinarians can advocate proper equine health care, and restricting discussion about equine health care to equine veterinarians significantly limits the advocacy potential within our profession. For example, the majority of horse owners also see a small animal veterinarian who cares for their pets and this small animal veterinarian will, on average, see this client twice as many times as the equine practitioner. The support of other veterinary professionals, including small animal practitioners, will reinforce our equine dental care education.
As horse owners become more aware of veterinary dentistry, veterinarians must be available to provide dental services. To ensure this availability, veterinarians who practice dentistry should establish referral relationships with neighboring colleagues and with other veterinary dental practitioners within their state. The bottom line is that an increasing number of horse owners are seeking dental care. While AAEP surveys indicate that the number of veterinarians practicing dentistry is much greater than the number of NVDCPs in North America, a quick Internet search demonstrates that the NVDCPs, rather than licensed veterinarians, have fully utilized this marketing platform. Horse owners who cannot locate a veterinarian to provide timely dental care services will solicit a NVDCP.
Finally, the best way to protect individual horses is through the education of horse owners and trainers so that they can make informed health care decisions. Consequently, the demand for NVDCP services will diminish. Equine practitioners need to take every opportunity to counter NVDCP marketing campaigns with appropriate client education. American citizens have an expectation of safe health care and government protection; therefore, many horse owners assume that anyone providing health care services is legitimate. To protect the welfare of the horse, veterinarians have a duty to dispel misinformation created through NVDCP marketing by promoting proper dental practice to the most influential decision maker in this debate — the horse owner.
Equine dentistry as a veterinary health care service is at a tipping point. Through aggressive marketing, NVDCPs have created a public perception of competency, and the failure of our profession to proactively educate equine health care decision-makers will result in continued deregulatory actions across North America. Ultimately, horse owners will choose who provides health care services for their horses, and some owners will choose NVDCPs. However, to protect the welfare of horses, veterinarians have a duty to educate equine health care decision-makers so that they can make informed choices. Currently we are not performing this duty adequately and horses are suffering as a result.
Dr. Stephen S. Galloway is an Equine Fellow of the Academy of Veterinary Dentistry and a former member of the AAEP Dentistry Committee (2006-2008). Dr. Lynn Caldwell is the chair of the AAEP Dentistry Committee.
To read more about the laws in Ohio concerning equine dental care, read “Equine dentistry: What’s the law?,” by Kim Lemmon.