Yes gingival flap closure should be allowable for Licensed Veterinary Technicians in the state of Virginia.  

I am against this proposal. Gingival flaps are one of the most difficult closures. Failure is common among veterinarians. I know this because I consult on problems like this with DVMs across the country. This is far different than closing a skin wound.

We should not put this into the hands of LVTs and I employ 3 LVTs.

Richard Freedman VMD

In my opinion, LVTs should be permitted to perform this surgical procedure, particularly those with VTS (Dental) credentials.  While all veterinarians will not want to take advantage of the assistance, this gives individual doctors the ability, on a case-by-case basis, to decide which technicians have the skill and experience to perform the procedure correctly and safely.

I am against LVT's suturing gingival flaps. There is no difference between this procedure and skin suturing for skill level  and maybe requires more skill level in some cases. Since VA board does not allow skin suturing by techs it seems to follow in same pattern for gingiva.

Ultimately the veterinarian is responsible for the quality of the work . Someday if techs need more skills to make their job interesting we could emphasize practice management or start with advanced certification for surgery ( in which case they might be able to suture)  or other specialties tha are currently available.

Techs are important in our practices and we need to make their jobs interesting and keep them learning. There is too much attrition in the LVT profession and people who are dissatisfied in their jobs.

Dr Mike Strickland

Leesburg Veterinary Hospital

I support the proposed changes to the definition of surgery to allow LVTs (especially those with VTS-VDT credentials) to perform gingival flap closures. While all veterinarians may not elect to utilize an LVT in this capacity, changing the definition will allow the veterinarian to decide, on a case-by-case basis, which technicians have the skill and experience to perform the procedure correctly and safely. 

Licensed Veterinary Technicians (LVTs) are already allowed to suture surgical skin incisions. Like veterinarians, LVTs are increasingly developing special areas of professional expertise, including specialist certification through the Academy of Veterinary Dental Technicians. They are already educated in tissue handing and suture placement. With proper instruction and oversight, many LVTs are perfectly capable of properly closing most gingival flap incisions. Of course, discretion of whether to allow a technician to close a particular incision, which technician to assign to the task, and ultimate responsibility for proper closure always rests with the veterinarian. In cases when a veterinarian has determined in his/her professional judgment that (s)he has an appropriately skilled LVT to properly suture a particular gingival flap, the regulations of the Commonwealth of Virginia should not supercede the veterinarian's clinical judgment.  

As a private practice owner practicing for almost 30 years, I know how difficult and complex these closures can be, and many will fail even in the best of hands. I don't believe LVT's, even competent ones, should perform this proceedure. Leave it to the veterinarians.

I am apposed to LVT's doing either of the mentioned procedures. Where are technicians going to gain training in these areas? Are the veterinarians going to provide full disclosure to their clients as to who is doing what? We know veterinarians have no training in oral surgery unless they seek it out on their own. Do you want your dental hygienist, who has much more training regarding the mouth than an LVT, closing you or your children's extraction/oral surgery sites?

Barron P. Hall, DVM

No, this opens a door that can't be closed and there are many practices in my area that allow UNLICENSED techs to do dentals, I'll bet they will let them close gingival flaps as well!  

The skills required to suture gingival flaps are no different than those needed to suture skin. My LVTs have been suturing for me up until this law change and have always displayed more than enough proficiency needed to do this in an efficient manner with high quality suturing. All LVTs, both experienced and newly graduated show the clinical skills needed and I trust them to perform gingival sutures on my patients

Dr. Michael Robinson

I vote against LVT's suturing gingival tissue.

Yes gingival flap closure should be allowable for Licensed Veterinary Technicians in the state of Virginia

I do not believe LVT's should be permitted to close gingival flaps associated with oral surgery and extractions.  These can be some of the most challenging surgical sites to close properly,  Suture selection, making sure that underlying bone has been smoothed properly to prevent sharp edges that may disrupt healing and ensuring that there is not too much tension on closure, all affect healing and successful outcome.  Many times size and degree of gingival and palatal elevation needs to be adjusted and tweaked during closure in order to maximize healing.  These are decisons that should be made by a veterinarian.

I do not support changing the definition of surgery to allow LVTs to suture gingival flaps.  LVTs are not formally trained in any form of surgery let alone oral surgery, and gingival flaps are not a surgical technique that is straight-forward or simple.  Think how much time is devoted in veterinary school to surgical training - surgery is not just placing sutures - it is assessing the viability of tissue, avoiding tension, and more importantly knowing what to do when things do not go according to plans.  Suturing within the closed tight space of an animal's mouth is technically challenging for vets many times, and it makes absolutely no sense to me to ammend the fairly clear cut definition of surgery (if cutting and suturing are not surgery, then what is?) for this particular procedure.  I see no benefit whatsoever of this proposed change to our patients.  Redefining the definition of surgery to fit whatever is economical or convenient it is a slippery slope that errodes the very clear distinction between doctor and support staff and compromises quality of care.  Would you want your own oral surgery performed by someone with unregulated and informal training?  If something goes wrong, the buck stops with the attending veterinarian's license, not the tech's.  Dentistry is an area of veterinary medicine where corners are already too commonly cut.  We should be working as a profession toward higher standards of care instead of lower, and should be valuing and utilizing our LVTs excellent educations to improve dental care appropriately.  When all patients undergoing dental procedures are getting full mouth radiographs, local blocks for extractions, intubation and excellent quality anesthesia, and multi-modal pain medication, then we can discuss finding more for our LVTs to do.  

If technicians are allowed to close skin, isn't the gingiva technically part of the integument system?  It seems to me the gingiva heals a lot faster than a skin incision.  In human medicine they don't even close extractions sites but approximate and allow the alveolus to heal from the inside out.  If a doctor feels the technician is competent enough to close the gingiva, then ultimately it falls back on the doctor anyway.

Our LVTs have been extremely proficient in suturing gingival flaps. The skill is no different than placing skin sutures and all sutures are checked by a doctor before the patient is woken up. If there is any doubt as to how to place the sutures or if the flap is sufficient then a doctor will close.

Yes gingival flap closure should be allowable for Licensed Veterinary Technicians in the state of Virginia.

I am in favor of this proposal. LVTs are highly qualified, and will be able to perform this task very well once tought how. Many DVMs are pressed for time, and by allowing LVTs to suture gingival flaps, you are allowing us to help you stay on schedule and not be over burdened. All the LVts at my practice are amazing, and more than competant. We are an assett to you. Use us!

This is coming from an LVT who is not at all dissatisfied in her job. I love what I do, but who doesn't want to be able to learn something new to add to their skill set? 

I highly support LVTs suturing flaps. One of our LVTs has been suturing for over 10 years and is amazing at it. She and they doctors have taught me and the rest of our LVTs how to suture properly. We very rarely have ever had a problem and have seen no difference since doctors only have been suturing. Dental procedures can last hours and can be very tiring for our doctors and now are even more so. With LVTs being able to suture this frees our Doctor up and allows us to do more procedures in one day. I think everyone needs to give LVTs more credit. We are educated and are good at what we do! Use us to the best of our abilities!!

If a licensed veterinary technician can perform a single layer closure of skin, I do not see why he/she cannot close a gingival flap as well under proper supervision.  I believe it is at the discretion of the veterinarian as to whether or not he/she allows the technician to perform the closure, but it should NOT be illegal for the technician to perform the closure.  As such, if a licensed technician wants to do the closure, and the veterinarian has confidence in him/her - then go for it!

With adequate training and supervision, this is a skill that can be safely and successfully completed by a LVT.

I agree that Licensed Veterinary Technicians should be allowed to perform gingival flap closure in the state of Virginia.

It is my opinion that a properly trained L.V.T. is certainly capable of surgically closing gingival tissue under the direct supervision of a veterinarian. 

I am against allowing LVT’s to close gingival flaps for multiple reasons:

1. LVTs have two years of general training to be assistants to veterinarians.Beyond a secondary education, this would be considered a generalized entry level education into anything.It is far from the criteria necessary to perform the practice of veterinary medicine and surgery.The licensing of veterinarians and veterinary practices has evolved out of necessity to protect the public.Any instrument applied to a tooth or the surrounding structures is unquestionably oral surgery and falls under the practice of veterinary medicine.Just as the pathway of human dentistry has lagged behind advancement in other areas of human health (but is catching up), the value of oral health care for animals and veterinary dentistry has lagged behind in our profession.As could easily be considered progressive many States and Provinces of Canada, have recognized the importance of dentistry and restricted the practice to licensed veterinarians.LVTs are restricted to assisting and not performing extractions and suturing.In the State of Virginia, LVTs are currently allowed to extract single rooted teeth.This aspect of the practice act is already abused.It is common knowledge that veterinarians regularly section multi-rooted teeth, refer to them as “single rooted teeth”, and then allow assistants to extract.The public is uninformed and unaware of this practice.Informed consent for LVTs performing even single root extractions is not provided in most practices.Allowing LVTs to suture will open additional abuse potential. Allowing assistants (LVTs) to perform dental surgery (extractions, suturing, etc.) is allowing the practice of veterinary medicine. Owners are usually uninformed when this does occur.

2. Oral cavity is part of the alimentary tract. Like other parts of our anatomy, the oral cavity has specialized, unique anatomy and properties.The anatomy of the gingiva is unlike skin, in that it is tightly bound down to bone. Because of this characteristic, it requires a distinctly different technique to release uninjured gingival tissue.It is VERY easy to tear the gingiva if this difference is not appreciated, or if insufficient effort is made to undermine the full height of the gingiva to allow the gingival tissue to be advanced over the alveolus following extraction.Insufficient releasing of the gingiva requires placing sutures under tension to obtain closure across the alveolus. The result is a guarantee of dehiscence a few days following surgery, with oral pain and bleeding.Sometimes there is sufficient gingival tissue undermined that the gingiva on the opposite side of the tooth does not need to be released. However, the usual techniques of placing a suture needle through skin will not work on this unreleased gingiva, and an individual not trained in oral surgery will very likely tear the gingiva and eliminate any possibility of satisfactory closure of the extraction site with uninjured gingiva.The mouth of a patient who has had extraction sites ‘closed’ by a veterinary technician who does not understand these nuances often looks like it has been butchered. These techniques specific to gingiva are not taught in veterinary technician school, and learning on the job is not satisfactory.

3. Just because the oral cavity is not in one’s normal view, and animals are able to endure significant levels of discomfort and pain, does not mean that conscious veterinary professional stewardship is not necessary.Handling of invaded dental and oral structures is the practice of veterinary medicine/surgery.Oversimplification of the facts is easy if one isn’t conscious of them and doesn’t have working knowledge of them.

4. The proper handling of each extraction site usually includes the necessity for alveoloplasty, osteoplasty, debridement of inflamed tissues, trimming of flap margins, proper subgingival curettage, proper lavaging, creation of mucogingival flaps using surgical instruments, proper release of tissue tension, selection of suture material type and proper suture placement.Each tooth is unique in this regard.Each closure site requires proper assessment and technique.Proper planning and technique factors play a major role in the reduction of complication rates, patient comfort and rate of return to normal functioning. There are several complications that may be associated with improper closure of extraction sites.Complications include: A) many extractions sites are not sutured closed.B) Unhealthy and compromised tissues may be present.C) Poor selection of suture needles and suture material may promote tearing of flaps, excessive inflammation, infection, sutures dissolving too soon, sutures dissolving too late. E) Strategic suture placement, positioning of sutures (spacing) and knot tying techniques are extremely important to optimum healing.

5. AVDT- LVTs do have additional training in veterinary dentistry, however, their more specific training is directed towards a more in depth understanding and proficiency in assisting the dentist…not performing procedures. At this point in time, AVDT trainees are not even allowed to be mentored by AVMA sanctioned board certified veterinary dentists.Adequate training for allowing procedures to be performed on someone’s pet would require a substantial increase in supervised, accredited and certified training.Again, learning on the job is not satisfactory.

Licensed Veterinary Technicians in Va are currently allowed to perform simple skin closures under the supervision of a veterinarian.  This change would only make sense.  It ultimately is up to the veterinarian to decide if his or her LVT is qualified to perform such procedures.   Like it or not veterinary medicine is becoming specialized. This means if you don't feel comfortable doing a procedure or task you can refer it to someone who does.  This would allow those technicians who seek speciality dentistry degrees. (Not AVDT but VTS those who pass speciality boards) the ability to assist the doctors in areas that they have far more training than most. 

I am SUPPORTIVE of this ammendment.

LVT's in Virginia can close skin- I would feel comfortable having the LVT's at a Vet practice do this procedure- we do about 24 dentals a year- mainly on dachshunds with horrible mouths. Our LVT's work side by side with the doctors as do most clinics- this would be a move in the right direction. Many LVT- do seek out more learning and specialty areas.

I believe that if a veterinarian feels that his/her LVT is skilled enough to perform this procedure, then it should be allowed.  I do understand that not all practices and LVTs may not be comfortable with this change, however, with all of the dental specialists we have (DVM and LVT) it would make sense that the LVT could be tasked with this procedure.  

I am in support of LVTs closing gingival tissue as long as there is adequate oversight. They are trained in suture closure and capable of such tasks. The DVM in charge must feel the closure is straight forward. Otherwise for complicated situations, I feel the DVM should be closing.   

I think as long as the LVT and DVM are comfortable with this, it should be allowed. I was just talking with one of my doctors yesterday about, how sometimes it takes longer to suture up that site than the actual extraction!! If we can free up the doctor, (we all know dentals are an LVTs job ;) and the docs just come in for the extractions) and help in any way we can, lets go for it! The motto at our clinic is: work smarter, not harder.  I don't want to speak for every clinic, of course.  I know some doctors enjoy dentistry, and suturing, and that's great!  It's just nice to have the option to help if the doctors are in a bind.  It's  important to stay open minded about these kinds of things, veterinary medicine is always changing and advancing in many ways!  

I have been watching the comments on this petition accumulate, paying particular attention to those from veterinarians.

Noting that some think the change would be fine but a larger number do not, I began to think that this should not be approved since there is no consensus within the veterinary profession about its safety.

And then on November 30 Dr. Thomas Chamberlain posted his long and detailed explanation of the reasons for his opposition, and with that it became clear that this should not go forward.  When a board certified veterinary dental specialist says that approving gingival suturing by LVTs would be a mistake, the Board should disapprove this petition.

As an aside, I note that he states that “In the State of Virginia, LVTs are currently allowed to extract single rooted teeth. This aspect of the practice act is already abused. It is common knowledge that veterinarians regularly section multi-rooted teeth, refer to them as “single rooted teeth”, and then allow assistants to extract. The public is uninformed and unaware of this practice. Informed consent for LVTs performing even single root extractions is not provided in most practices. Allowing LVTs to suture will open additional abuse potential. Allowing assistants (LVTs) to perform dental surgery (extractions, suturing, etc.) is allowing the practice of veterinary medicine. Owners are usually uninformed when this does occur.”

I have had a total of nine cats in my care over a 44 year period, and as I have moved around the country I have taken them to 5 primary care practices and 3 specialty practices.  At no time has any veterinarian ever said to me “I will be doing this and my LVT will be doing that.”  And I certainly don’t want an LVT performing any aspect of oral surgery on any of my cats