"The Perfect Partnership" The General Practice-Dental Specialty Referral Relationship

In this episode of the Pawsitive Veterinary Dentistry Podcast, host Benita Altier sits down with Dr. Naomi Hoyer, DVM, DAVDC, to explore the vital relationship between general practitioners and specialty veterinary dentistry.

Together, they discuss how to recognize when a dental referral is appropriate, what the referral process actually looks like, and how collaborative case management can lead to better outcomes for everyone involved — the general practitioner, the client, and most importantly, the patient.

Dr. Hoyer shares real-world case examples, practical decision-making tips, and insight into how referral partnerships enhance patient care while strengthening trust between veterinary teams. Whether you’re unsure when to refer, curious about what happens after the referral, or looking to build stronger specialty relationships, this episode provides clarity, confidence, and actionable guidance.

Key Takeaways:

• How to identify cases that benefit from dental specialty referral
• What to expect before, during, and after the referral process
• Why referrals improve patient outcomes and client trust
• How collaboration supports long-term practice success

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Transcript

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: [00:00:00] Welcome to the Pawsitive Veterinary Dentistry Podcast, the show for veterinary professionals who want to elevate patient care, improve dental confidence, and bring clarity to the most overlooked part of veterinary medicine. The mouth. I'm your host, Benita Altier, Licensed Veterinary Technician, Veterinary Technician Specialist in Dentistry.

We're kicking off our very first episode with someone truly exceptional in our field. Dr. Naomi Hoyer is a Boarded Veterinary Dentist, Assistant Professor of Dentistry and Oral Surgery at Colorado State University's James L Voss teaching hospital. She graduated from Colorado State University with her DVM in 2002.

Spent 10 years in general practice and then transitioned into specialty training and dentistry, becoming board-certified in 2017.

 In 2018, she left private practice to begin teaching full-time because her passion in veterinary dentistry drove her to that destiny. I have the great [00:01:00] pleasure of getting to know Dr. Hoyer over the past several years, teaching alongside her at several labs that we've done together, which have been just amazing to get to know her and gain a deeper understanding of her extensive knowledge and experience in the field.

She's an incredible teacher and truly a talent to help you get some practical knowledge and helpful insights, I feel veterinary professionals can really use. Dr. Hoyer, thank you so much for being here to help us explore a question that I think most veterinary practices really struggle with, and that's when to refer dental cases and what makes a referral successful.

So welcome. Okay. 

Naomi Hoyer: Well, thank you so much, Benita. I really appreciate the chance to be here.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: yeah, absolutely. So can you share just a little bit about your journey and what inspired you to pursue dentistry after a decade in general practice? 

Naomi Hoyer: Yeah, so I started in general practice back when I graduated from veterinary school in 2002, and actually started in mixed animal practice, which I loved. But after I had done that for a few years, I just started feeling myself wanting to have to be a little bit of an expert and [00:02:00] less things and starting to get to kind of focus in on some things. So I went from mixed animal practice to small animal practice and as I was in small animal practice, I think like many of us, I was, around a lot of people who just didn't love dentistry. The work that we do in general practice often feels really stressful and hard for a lot of people, but I actually kind of liked it and so I started doing continuing education courses, just did more and more of them. And so because I was working in a big multi-doctor practice, I ended up being the doctor at this big practice that did most of the dentistry cases in our GP and just loved it more and more and more. And then finally got to the point where I thought, you know, if I'm gonna do this. Full-time, I would like to go back and pursue my specialty.

And so entered into a residency program and then finished. And then I really felt like the most important part of being a veterinary dentist for me was contributing to education. So less people felt like they came out of veterinary school like I did, and just didn't know anything about dentistry. So that is what I do now, which is teaching hopefully the next generation of general practitioners not to be terrified of dentistry.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: [00:03:00] That's really amazing thing because when you get the opportunity to help people just like yourself, struggle a little bit less and really feel more confident, in the beginning, they may come out into practice and not really feel like they like dentistry or they don't know anything about it, so they just don't even feel like they're confident enough to give it a try well, I, for one, I'm really glad that you made that choice, because I may not have met you

Naomi Hoyer: still just be sitting in my little tiny room taking out teeth all day. So

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: which is, amazing, important pursuit. Absolutely. But like me, I'm sure you feel the same, where if you can get out there and teach more people, then you can impact a lot more animals' lives and really people's lives in the end, that really important human animal bond that we all share with our pets.

So what motivated you to move into academic teaching specifically at Colorado State University? 

Naomi Hoyer: It was sort of a combination like of many things in life where it was like the perfect timing. So there was an opening at CSU, so one of their veterinary, dental specialists left. And I [00:04:00] was, working private specialty practice sort of in a couple of different areas and just feeling, like I'd just become board certified, was trying to decide what path I wanted to go on. And it was very clear that I was passionate about and really loved education and sort of was like, you know what, if I'm gonna, if I'm gonna walk that walk, the best place to do it is at a veterinary school.

So I went in sort of thinking, you know, maybe I'll do this for a few years. But it's just turned out to be my greatest passion for sure. I just love educating.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I noticed that in your biography you have a specific passion for congenital maxillofacial defects and regional anesthesia. So how did those become something that you are really passionate about? 

Naomi Hoyer: The practice where I worked when I was in my dental residency, one of the other specialists at the practice was a theoryogenologist. So we did a tremendous number of C-sections in our practice, and as a result of that, we diagnosed a lot of puppies with cleft palates at birth. I developed sort of a passion project for helping people who are interested in raising cleft palate puppies.

And then we would do a lot of cleft palate repairs. [00:05:00] So it was something I started doing really early in my residency that I just absolutely loved and have continued to love. And so that is where that came from. I love it. And regionally, anesthesia, you know, I can't remember who said it, but somebody said at one point, dentistry when done well is. Pain control and I so feel like that is true. So many of our patients are suffering from oral and maxillofacial pain that they can't really describe as a feeling to their owners. And, the combination of good, safe regional anesthetic plus dentistry for me is the best pain control that I can provide for my patients.

So, 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I can't agree more. It really is all about pain management.

Naomi Hoyer: I, yeah, I'm just such a huge, huge advocate, not only during our anesthetic procedures, but then perioperatively and thinking about long term, like pain management I think is just so important for our veterinary patients.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Let's get into the big question. So when should a GP refer a patient? 

Naomi Hoyer: I think it's such a good question and I think there's so many different layers to the answers. So I would say there are certain kinds of cases. I think first of all always like my answer in veterinary medicine in general always is [00:06:00] it depends. So it depends on the GPS level of,. Comfort with dentistry? It depends on resources in your practice for safe anesthesia. It depends on time, resources in your practice, do you have the ability to do lots of big extensive dental cases, which means you can't then be doing other kinds of surgical cases? 'cause we all know dentistry takes a lot longer. So I think the answer is, it depends. I think there's a. A few different case categories. So I would say orthodontics is one. So if we're putting braces on a dog, it probably needs to go to a specialist. I think there's some bigger maxillofacial surgeries, so some of our like big tumor surgeries, lots of our big trauma cases that probably need to go, and at least have some board certified dentist involvement. Some of our endodontic procedures. So in general, most general practitioners aren't providing things like root canals or vital pulp therapies. And then I think the other big category that, you know, hopefully we'll have a chance to talk about a little bit is just our patients with increased anesthetic risk. So I, I'd say probably a third of my caseload right now, particularly 'cause I'm at the university, isn't necessarily a [00:07:00] case where the dental disease isn't something that GP could manage, but the GP maybe really does not wanna tackle the anesthetic risk associated with that particular patient. And I think that's a category sometimes we forget about how important that is.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I would agree with you and I do hear general practitioners sometimes being really hesitant to anesthetize a patient to perform dental procedures because of the patient's age or comorbidities. I know we always say age isn't a disease, however, I know that's still a concern that many general practitioners have.

 Another thing that I hear sometimes is that general practitioners are really thinking about keeping the revenue that's generated from dentistry cases in hospital versus referring. How do you feel about that? I know we're not asking people to refer just so that we can do all of the dentistry or steal all of the cases.

Naomi Hoyer: I am here to steal all your cases

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yes.

Naomi Hoyer: Not. No, I for me the reality is, there just are not that many board certified dentists in the [00:08:00] world really. I think we're up to maybe a 250. Now. There is just not a way for all of the dentistry that needs to be done for all of our patients to be done by the specialists.

So the thing I find is that the more educated and the more, comfortable with dentistry, my referring base is, the better, like the better for the patients. 'cause I, I really don't, I would love it if I didn't have to have patients that were just here because, GPs didn't feel comfortable with extractions. Then maybe you guys just sent me your big maxillofacial surgery cases or big trauma cases, things like that. Because I find that many times owners bock at the prices when they come see me. Or owners just don't feel comfortable with me because they see you for everything. You know, a general practitioner is the person you bring your puppy to, and they are seeing this pet every year. So I think it would be amazing if general practices felt comfortable doing most of the dentistry and then there's just this relationship where like, hmm, there's just this level of case where I don't want to, I can't, whatever the reasons are.

Then you can send that to me and I'm here as a resource for you.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: you are such an amazing [00:09:00] resource and paralleling that to human medicine, I think that more people understand that they're probably going to need to go to specialty medicine in my 37 years of doing this profession, we've really seen a different way of doing things in regards to when I started, I used to think, oh my gosh the veterinarian is the hero of all things. They would tackle anything because honestly there was nowhere else for them to go, if they didn't help this patient, there was no place for them to take this animal.

So the vets just did everything that they could to be the all for the client and for the patient, but nobody can be good at everything and like you said in the beginning, I just can't be good at everything. I'm gonna figure out something that I really like to work on and try to get the best at that.

Another thing I will emphasize, and you can speak on this as well, is that if a patient is a little bit higher risk on their anesthetic ASA level, you may really want a veterinary dentist to be doing even some of the things that a GP could [00:10:00] do because you're more efficient, probably just even faster, to minimize the patient's time under anesthesia

how do you feel a GP doctor should parse that out when it comes to deciding whether maybe a veterinary dentist would be a good place for them to be? 

Yeah, 

Naomi Hoyer: I mean I think, again, it sort of depends 'cause I definitely know some very competent GP practitioners who have been doing dentistry really well for a long time, who are very efficient and have really well trained staff. And so I think for those., I just really don't, there may not even be a reason to refer, but I'm thinking more of you're two to five years out of school, you're doing dentistry, you're liking it, and you're still sort of developing those hand skills to get more efficient.

And let's maybe say you see a dog that needs 35 plus extractions. And so your practice can offer that. And sometimes I encourage people to think about staged procedures. So you spread the anesthesia procedure out into two instead of just one to minimize the length of each procedure. But maybe it's really better for that patient to just have one procedure.

So that might be an example of a case where we're [00:11:00] like, well actually, maybe it would be better for this one to go to some place where they had anesthesia support and then a board certified dentist. So while I really think it depends, I do think you just kind of have to in, the longer you dentistry, the more you understand, like, I understand that these extractions will probably take me, you know, in your mind let's say a half an hour or 45 minutes. And I feel like that's actually a really important skill that people need to develop over time is just understanding. You look at an awake dog's mouth, understanding how long you think it's gonna take you to do the work that needs to be done, and then planning appropriately. I do think it's important for every general practice to decide for themselves and that the number is often different at different practices. How long do I feel comfortable having a patient under anesthesia in my practice? Because one of the most heartbreaking things for me is I talk to graduates who, you know, they've been out a couple years.

They call me with some oh my gosh, I had. Case under anesthesia for six hours. It was terrible. I was exhausted maybe the dog wasn't doing well under anesthesia. So, you know, those are the kinds of situations where I hate that people get involved in because they just feel terrible. And then it leaves [00:12:00] kind of this bad taste in your own mouth about dentistry.

Even if the patient does great, not fun to think about having a patient under anesthesia for five hours. So. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Dentistry is often turned into a marathon when the veterinarian has a lot of extractions or treatment to do, and mental and physical fatigue can really set in. And when you're doing something that's so draining for potentially hours on end, it may be really stressful and cause the veterinarian to be reluctant to tackle a case like that again.

Naomi Hoyer: I am a big fan of setting yourself up for success, so whenever possible, let's do that.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yes, I agree with that. So what do you think are the risks when a complicated case is attempted without advanced training equipment or imaging?

Naomi Hoyer: The biggest risks obviously are always like if something goes terribly wrong. So if, if there's an error that happens, or even if it's just like a known anesthetic risk in a patient 

patient who, maybe has high comorbidities, I think. As we all know, every single time we have patients anesthetized, the risk of major anesthetic [00:13:00] complications are real.

And I think that's really hard because I, again, like the worst thing for me is you talk to somebody who's had a really negative experience with dentistry and then they're just like, I just don't wanna do it anymore. That's hard on you. That's hard on your patients because then you're not able to provide all of that care that they could just, it's so hard. So having good screenings, having good protocols in your hospital, what are the kinds of cases that maybe we don't feel comfortable anesthetizing in our practice, or like the kinds of cases that we don't feel comfortable tackling.

So it's just an open conversation that everybody can be on the same page about, I think are really important ways to prevent that from happening.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yeah, absolutely. And I think a lot of things that you and I both see out there in the world can really be solved with some really good strategic planning conversations and honestly ongoing training. Right? And not just for the veterinarians, but the whole entire staff. And then they have a better idea of how to decide if this patient is a patient, they feel comfortable with treating in their hospital, or they may feel more comfortable at least offering the client referral for that [00:14:00] patient or maybe staging the cases so that they do their best to mitigate the risk to the patient because I know we all wanna make sure they're safe and that they're treated, with the utmost care that we can give them.

Naomi Hoyer: Yeah I think you bring up an interesting point, which is just that you cannot, it does not matter how good you're at dentistry if you don't have good support staff around you, your support staff in general is the team that's monitoring anesthesia, so they need training for that.

Hopefully they're taking your rads, hopefully they're helping you with oral exams. Hope, I mean, there's just so many parts of having every part of your team be good at dentistry. So having a good, well-trained team is just critical. I could not do my job without it a hundred percent.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I really agree. So with the cases that you've seen at CSU, has there been any cases that you, or any specific condition or situation where you kind of say to yourself, gosh, I wish we would've seen this sooner.

Naomi Hoyer: I would say the, it's not so much a specific condition, but I do think there's one. And I always like to preface this by saying there are some times that I note, 'cause I was a GP and I would say [00:15:00] something to an owner, I would write it in my record and then the owner would go and tell a specialist something entirely different.

That sort of made me look like a huge jerk. And I was like, that is not what I said. But I do think. Sometimes, even if it's that we give the impression in general practice, we see a lot of patients who come in and the owners are under the impression that their dog has reached this magic age where we can no longer safely anesthetize it.

And usually that age is around 13 years old. So we'll have an owner come to us. And again, I don't, maybe that the general practitioners have never said anything like this. But sometimes I do think that like we put so much emphasis on the increased risk associated with age, that then this dog, let's say, I'm gonna just pick on a particular breed.

Let's say this is a dachshund, so maybe at 13 this owner hears that this dog is too old. , And maybe there isn't any big comorbidities. Maybe it's just a 13-year-old dog who's relatively healthier. Maybe it has like early stage mitral disease. And then this dog proceeds to live to be like 16 years old and it's had no anesthetized dentistry for three years.

And then I am [00:16:00] seeing this dog at 16 years old because now it needs full mouth extractions. And so I think those, honestly, I think that is such a hard place because in my opinion, I always, if I'm faced with a stable. 13-year-old dog man, I would love to get that dog under anesthesia. I'd say my average age that I anesthetize a patient is probably 13 to 14. And so I think just being really careful about how we communicate about that with owners, because I do think there's just owners have a lot of fear. And then we just need to communicate in a way that indicates that like, Hey, I might not feel comfortable with this in my practice. So when I was in gp, we had an anesthesiologist who would come in and help support me when I was doing those older cases. I tried to be very, I mean, there is a handful of cases in my career that I have actually said like, this dog is not safe to anesthetize. But for the thousands of procedures that I've done, it's maybe a dozen.

It's a great place to, to really leverage that referral relationship you, that you have. 'cause I think, I mean, I get emails all the time. I call myself a dentist in a pocket. Like I want you to think about texting me, emailing me, and [00:17:00] saying Hey, I've got this case.

Do you think this would be an appropriate one for referral and I'm always happy to, have the owners come in for a consult. We have a big conversation with them. They don't have to schedule a procedure with us, but it just really allows us to sit down, review the records, talk to owners about like, Hey, here are the pluses and minuses.

Here's what the options are so that we really are taking the time, which again, as a general practitioner, I did not have time to spend an hour talking to an owner about dentistry cases. So for me, it's a great opportunity to be that person who has to sit, review all those records and have those conversations with the owners.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: What a great resource, because honestly, like you said, they don't have to decide to go ahead,

Naomi Hoyer: we have tons of people who just come and see us for the consults. As a matter of fact, now we do some telehealth appointments where it's somebody who's really far away who just wants me to look at the records, talk through kind of the risk, and just think about in a specific way, does this make sense for my pet?

I think it's a great option. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: the veterinary dentist may even tell the general practitioner that they probably can handle this case. Given what you're seeing, or it could be that you think [00:18:00] that this would be a really great case to refer and you could then give the general practitioner some feedback so that they could get better and maybe be able to tackle that case on their own in the future.

Also, I would say that dentistry generally gets worse over time as far as if it's not addressed. So we certainly don't want to have these things get away from us because we definitely don't want to wind up having to extract more teeth or potentially have more expensive treatment that needs to be tackled in the future. The funny thing is we have to combat things like the owner's thinking we "love extracting teeth just for fun". We wanna make their pets teethless.

Naomi Hoyer: It always makes me laugh when owners say like, only take out teeth that have to be extracted. I'm like, you have clearly never extracted a tooth. I would never take out a tooth that does not have to be extracted.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yeah, the old saying, it's like pulling teeth is for a reason,

Naomi Hoyer: yeah. Oh, for sure, absolutely. yep. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I follow different people on Facebook that, these groups that post up cases and they show [00:19:00] radiographs and they, talk about the case and they're not knowing what to do. And a lot of times they're showing us some radiographs. Are there any specific radiographic or actual clinical findings where you're probing and charting that would make a GP stop and say, I need to refer this case?

Naomi Hoyer: Maybe not even referral, but maybe, there are services out there where you can send radiographs in for review. I think the cases that have, that stick in my mind where a GP really honestly has saved the day is where during the course of an anesthetized dental procedure, a GP identifies something. Suspicious that just kind of like, kind of tickles a nerve ends up being really early oral cancer then we can provide really definitive treatment for. And so I have like two that pop into my mind. Initially, we had a great, one of our great referring partners had just identified kind of this round spot. Um, it was less than a centimeter right on the surface of this dog's palate during an anesthetized dental procedure. The dog of course was fine. No clinical signs, nothing. There was no problems. That [00:20:00] particular one they sent to us for a biopsy. I don't like, they probably could have done the biopsy, but they just felt more comfortable 'cause it was on the pal. And that ended up actually being an osteosarcoma. Which then we were able to do surgery for. And that dog is alive two years later and that dog is only alive because that general practitioner noticed that something was weird and did something about it. We had another really great case where we had one of our, referring partners who.

There was what looked like a cystic lesion in the dog's mandible. So it was like this radiolucent lesion. It was near a tooth. She got a biopsy, which actually came back as a cyst, but then it just continued to grow. And there was just something about that with her that really didn't sit right, like she just was like, cat, this biopsy doesn't fit what I'm seeing in the dog.

And so she sent it to us. We got a bigger sample and it turned out to be a kind of. Tumor called a conventional ameloblastoma, which just if left untreated, would've expanded and expanded and basically eaten this dog's jaw away. So in both of those cases, it, you know, if that dog, if we had waited for that dog to become clinically affected by that disease,, we would not have [00:21:00] had. good treatment options. but both of these general practitioners really truly saved these dogs' lives because the osteosarcoma for sure would not have been as good of a prognosis. The ameloblastoma would've needed very significant surgery on the mandible, and it was just the GP and then their relationship with us that allowed those dogs to have really positive outcomes.

So GPs, they're, they're the people on the ground doing the hard work every day, and hopefully we are just there to support them.

You just like, you can save lives all of the time, just doing good, good oral exams

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: and doing it at least on some sort of routine basis, right? So that years and years don't go by. Because these lives are so sped up that, even in one year a lot can happen. And I also tell people if they animal has no teeth left, zero teeth, it still doesn't mean that we shouldn't be looking in the mouth.

 right. Because of all these reasons that you just mentioned. So we can make sure there's nothing else in there that we need to be addressing. 

Naomi Hoyer: You can see a lot on a conscious oral exam if you learn how to a good conscious oil exam really well, which I think [00:22:00] is really important. But I do think there's just some stuff we can't see during anesthetized oral exams that are super important. So I would love to have a patient.

Get an anesthetized exam every year. Now, again, I know that not every client is gonna be able to afford that, gonna listen to your recommendations, but at least if you're recommending it to everyone, you're gonna get more than if you don't recommend it at all. So,

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: absolutely. And you know, they say, the clients have to hear things 2, 3, 4 times from four different people. Because sometimes they just don't understand Something like you said, could even detect something that could potentially save their pet's life or, give them a better quality of life for what life they have, 

Naomi Hoyer: Yeah absolutely. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: can you think of any cases where there was some sort of misinterpretation of the clinical or radiographic findings that potentially delayed referral, has there been any cases that you know of where the GP was a little unsure of what they were seeing clinically or radiographically and hesitated?

Naomi Hoyer: I'll tell you what pops into my mind right when you say this. The big one for me that sticks out is [00:23:00] the watch and wait. And we see this in relation to, unfortunately, sometimes we see it with oral tumors. So we have had some cases where, yeah. Instead of rec, I'm a pretty big advocate for biopsying.

Anything you see in the oral cavity pretty early. ' cause if it's benign, great. If it's aggressive, you might have saved the pet's life. We always say there just isn't that much real estate in the maxillofacial region. Like we just don't have that much room to take out a tumor. So if we can get a biopsy, even if it's just to give the owner the information to know what it is. We just had a case this week of a dog who has what Probably is a melanoma. The owner's not gonna do a big, giant surgery or radiation or chemo or any of those things, but she just wants the answer. So we did a biopsy for that dog. We're still waiting for the results. But man, I think watch and wait is just about the worst advice that we can give owners when it comes to stuff in the face.

Because if you don't have X-ray vision, which of course none of us do, I wish I did.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: We did not get that with our education.

Naomi Hoyer: I know exactly. But it's just what you're waiting for. Often by the time you see that, it's then too late. Like we've run out of treatment options. Um, so I think tumors is one place where I see that a lot.

And then [00:24:00] unfortunately, broken teeth, which also drives me crazy so if you see. a tooth that has a complicated crown fracture watch and wait is never on my list of what to recommend. Again, the owner might decline your recommendation, but if you see a complicated crown fracture, meaning I can see down into the pulp of the tooth, it either needs to have a root canal or it should come out.

' cause what you're watching and waiting for is an abscess and the dog can't advocate for herself. So I definitely think those are the places that really, it's like, oh man., If the owner decides to watch and wait, that's one thing, but I don't ever want a GP to be the person who recommends that.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: That is such good advice because I think somehow in my observations, the GPs tend to be a little hesitant about asking the client to spend money or to go for referral because we're so concerned about them and their pocketbook, which I understand we are all humans and we all have to try and make ends meet they're coming to us to be the professionals, to be the patient advocate and so we really wanna convey that to them so that they know this is our professional recommendation and then [00:25:00] leave it at that. Because if you backpedal that recommendation and say, oh well, if you want, you could probably just watch it.

It just. Goes on from there where we really didn't want them to go in the first place, which was just to watch and wait

Naomi Hoyer: yeah i'm a huge advocate of like forcing the owner to decide. So I give them what I recommend. I'm not gonna strong arm them into it, but then if something goes terribly wrong with it and I was the one who recommended, Hey, let's do a biopsy, or, Hey, I'd really love to refer you for treatment of this tooth, I understand like the cost of referral care is really high in this country. And so there are clients who just cannot accept that, but then offering them. Something that you could do in your practice. Like it doesn't have to have a root canal. You can extract that tooth. There's no reason why a tooth can't be extracted. Just as make sure that we're giving options.

That actually makes sense.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: they don't have to pick the most expensive option if that's not what they want.

Like you mentioned, the idea of doing nothing is really not acceptable. So let's try to steer them towards what they can do and that's setting them up for success

along the lines of client [00:26:00] communication what should a GP tell them? If they say they just can't afford it. They just don't have the money. I know our bleeding hearts unite. We don't want them to not get what they need. The pets need this.

We're not saying something they don't need, but sometimes the clients just can't do it.

Naomi Hoyer: All the time. I would say it's, a really regular problem. because dentistry is expensive. We can't do dentistry without anesthesia. We have to have support staff. So all of these things contribute to the cost of dentistry I would understand in your area what your options are.

So we fortunately have some low cost options that we can use as referrals. I know actually for big procedures like maxillofacial trauma or tumors, we have what we call crowdfunding. So people who go to GoFundMe campaigns and things like that to try to get something for their pet. Um, we have some practices that I know of that sort of say, okay, like this is what I would recommend if we were gonna do all the work. But if we're gonna do. A shorter procedure where just addressing the issues that are affecting the dog right now that can make things less expensive. Um, some [00:27:00] practices have payment plans.

We have things like CareCredit, I think there's a lot of creative ways for practices to try to work together. But it's hard. Like, I, I don't wanna underemphasize how challenging that can be for practices many people are not prepared to have a big cost that's associated with a big dental disease unexpectedly.

So I think it can be incredibly challenging.

Is just to work as a practice, understand the resources in your area that can help with that so that you have as many options that you can to offer owners.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: maybe pre-prepare a document that you could hand out or email with, these are the resources that we are aware of in our area, and these are some things that may be possible for your pet. I think too, one thing to notice is that dentistry is often not an acute situation. Some things can be acute, right? A lot of times what we deal with on a daily basis in general practice, are things that are preventable. If we would've just had a more impactful conversation with a client when they got the new puppy, right, when they're [00:28:00] so excited about the new puppy or kitten, and just knowing that dentistry is a part of their wellness care and it really should be a lifelong pursuit, and really helping them plan for that

I always think it's disappointing that we don't actually tell them what the annual cost of dentistry is because it shouldn't be a surprise, or we shouldn't wait until they actually have something that's going to require surgical approaches or more intervention that becomes more expensive. If we could have just went down the road of, prevention and be proactive how do we talk to clients about these things to get them to understand that, want them on our team and we all are working together to hopefully prevent them from ever having to get to a place where they need to see you.

Naomi Hoyer: Yeah. I think dentistry as prevention. It is like my pet project to try to get dentistry moved into prevention, just like we think about heartworm and vaccines. Um, because man, it'd be great for me if I never had to take all of the teeth out of anybody because.

GPs. Were doing such a great [00:29:00] job teaching owners about home care and then teaching and performing good preventive procedures. I know we're a long ways off from that, and I know there's a zillion different reasons. A lot of it is owner compliance, but whew.

Make that change, I would love it.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: if someone does refer to someone like yourself, what kind of wait time is involved in that?

Naomi Hoyer: It really depends. We do triage scheduling, so we have emergencies come in, we see them the same day. Tumors, we try to get in a week to two weeks, depending on the severity of the tumor. Chronic perio, tooth resorption, things like that. That may wait a few weeks before we can get it in. Maybe even a couple months, depending on the time of year. We certainly, like a lot of people, we have like seasons of cyclical busyness that we have. Yeah, so I think it, it really depends on the severity of feline chronic gingivo stomatitis cases. We try to get in really early because by the time we see those, often they're not eating well and we wanna try to get on that management as soon as possible.

So it, for us, it depends on the kind of case.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: great to know. I think that's a great thing for a GP veterinarian to ask their local veterinary dentist, or as local as you can, find [00:30:00] someone like yourself, because they may decide not to refer just because they think it's gonna take too long to get in with you. And that could be a thing, but you're triaging the most important cases first. 

Naomi Hoyer: absolutely. I think that's why it's so great to figure out who your local veterinary dentist is. That's gonna be your best referring partner and understand how so you're not gonna refer a person to somebody for something acute if they can't get in with them for seven weeks. And so you just need, 'cause every veterinary dentist, just like every other specialist, is just a little different in how their practice runs.

I'm lucky enough to work in a big hospital where we have a huge urgent emergent care. So we have the ability to get cases in that need care right away. which is really great, but not every dentist is in that boat. So

understanding your referring hospital is important.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I definitely always strongly encourage that because I feel like if they get in that situation where they have that case, they need to understand what the process is to get in with you and be able to, even, like you said, have a veterinary dentist in your pocket where you could, potentially [00:31:00] text someone some images and signalment and some information

A lot of times they actually are under anesthesia already when they realize that this is not something they're comfortable with tackling and they need to be able to discern whether it is really something I could go ahead and do or not. And that's sometimes a stat kind of thing when they're already under anesthesia. Is there a case that you wanna share with us today that you would like to give us as an example of a referral case? Help someone understand what it might look like for a specific patient, which we're gonna keep anonymous, but something that would help them understand the process that happened with this patient.

Naomi Hoyer: Yeah, so I think, the, my favorite one to talk about is the dog who had the mass on his palate. So this was a veterinarian who had the dog under anesthesia notice the mass on the palate she didn't feel comfortable doing this biopsy, so she. Took a lot of pictures, woke the dog up, and then called us and was like, Hey, what can I prepare this owner for? We had the owner come in for a consult, [00:32:00] talked about a whole bunch of different options for what we could do. Did the initial procedure, which was then a CT and a biopsy. To get a whole lot of information about what was going on. Sent the dog home that night. Dog did great after the biopsy, and then got our biopsy, our initial biopsy back about a week later, which showed that the tumor was an osteosarcoma. And then had a long phone conversation with the owner about what her goals were. How. Extensive, did she wanna have surgery? Was the most important thing to her, whether the dog lived the most time or whether, because if you're doing surgery on the palate, unfortunately sometimes there are surgeries that you can do that the dog will experience side effects from those surgeries long term. so we just. Really wanted to be a partner in the owner. And then after all these consultations, I called the referring veterinarian just to let her know where the owner's head was. So we had the dog come back, did some staging, and then did a surgery to remove a portion of the palate. and then did surgery on the palate to prevent an oro nasal fistula from forming, which is what the owner was very clear about.

Her goal is that I don't want that for my dog. We were able to get good margins 'cause this vet had found this so early and now we have the [00:33:00] dog come back every six months for repeat staging and repeat imaging. And so far no evidence of recurrence. A weird thing about osteosarcoma in the bones of the face is that it actually often is less aggressive than appendicular osteosarcoma, which I think is surprising for some people. but you have to find it small so that we have the ability to get good margin. So I think it was just a. Case where a vet found something she wasn't expecting. They just thought this dog was coming in to have a tooth extracted. Handled it exactly the right way, which was like, Hey, to the owner, I just don't know what this is.

I'm gonna take some pictures, I'm gonna reach out to my referral partner. We're gonna come up with a plan. Had lots of communication, both with the owner and with the RDVM. This owner actually comes from really far away. She actually comes from out of state. So the referring partner is a really important piece of that role for us, because there's no way we're gonna see that dog as often as it needs to be seen for follow up. So we spend a lot of time talking with her about Hey, here's what to expect. Here's what if there's a problem. And so I think it was just a perfect example of the best case scenario for primary and referring DVM.

The owner feels supported by both people, [00:34:00] where everybody's on the same page for this dog's long-term success. Even for an owner has to come really far away. I think this owner feels like absolutely my primary vet made the best decision for my pet. And as a result of that, like this dog is alive would not be 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: had this particular GP already known about you guys or had referred patients to you?

Naomi Hoyer: yeah. Dentistry there are places we call 'em dentistry deserts where there just aren't board certified dentists really close to some people. Or maybe there's a board certified dentist, but maybe they're at a kind of a smaller specialty practice. And that's the situation for this.

So we're the closest, we're about eight and a half hours away from this person, but we're the closest big referral center to them, just because they live in kind of a remote location. and so she has referred cases here before and I think I provide continuing education. So I think she had met me at a conference and we just talked about Hey, what are the best strategies for, if I'm referring people from really far away how can we make this work best for both of us?

So she is a partner that we love working with. We don't, we probably only see maybe two or three cases from her a year. Because she's had to push her envelope a lot with like how [00:35:00] comfortable she feels doing stuff. 'cause she has clients who are like, oh, I cannot afford that. I can't take that time off work. And then, she'll send x-rays, we'll talk to her about cases. So it's a great, it's just a great example of how you can work well with a referring partner.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I was just thinking of this when you mentioned this particular case because thinking the GP saw this in the mouth, how did it pop into her head to think, oh, I should actually do what she did versus, I think of lot of GPs that haven't previously established a relationship with referring practice like yours.

They may not think of that in the first place. I think a great way to make this particular episode really purposeful is just getting people aware that should be something that pops into their head to think, hey, that could be something that would be appropriate for this particular situation, versus maybe trying to just tackle it.

Do you think that would've been a good idea for her to biopsy that on her own or versus saying, Hey, let's let the dentist [00:36:00] or the referral practice go ahead and start from the beginning. 'cause you mentioned she just took pictures versus, starting to make incisions. So what would you say would be a good rule of thumb when it comes to something like that? 

Naomi Hoyer: I think for that one, for me again, depends entirely. Like she probably would've done a biopsy if it was someplace other than the palate, I think. 'cause it was on the palate. She was like I don't know. I don't necessarily wanna cut into something and find a giant hole and make a fistula. But I think if it had been on the gingiva, she probably

would've done a biopsy I think it depends on where the mass is. Is the GP level's comfort? That may also be a case where you, every once in a while we'll have a referring vet kind of call us on a more emergent basis. Hey, I've got this case under anesthesia and I'm looking for some help thinking about this.

And so we'll talk to our referring partners about, like me, like you could think about getting a biopsy here, but maybe send it. I think it's always okay for GPS to get biopsies ahead of time, as long as they're thinking about Hey, if this owner wants to go for more surgery, let me make sure that my biopsy . isn't gonna affect the surgery. So

of that is just GP comfort.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yeah, absolutely. And obviously the [00:37:00] photographs and maybe doing some measurements of the mass with your periodontal probe 'cause you've got millimeter markings on the probe. 

Naomi Hoyer: Yep.

Yep that what she did Just held her probe up to it. It was perfect.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Yep. 

Get all your dimensions down. Photographs, imaging, and I think you mentioned something earlier that I feel is important to emphasize is if they do refer to a place like CSU or a specialty practice, more than likely you guys are gonna have advanced imaging, which. Cone Beam CT has really made a huge debut and been really successfully integrated into a lot of the vet specialty practices, and really that gives you a lot more information than what they could really discern on their own.

Is that correct?

Naomi Hoyer: Yeah. Again, I think it depends on the mass. If this had been like a rostral mandibular mass, she's gonna be able to see a lot with her dental rads. It's something on the palate. And then TMJ and the caudal maxilla, even on the far caudal mandible, like three dimensional imaging is gonna be a pretty important piece of that.

And so that is always a factor when we're talking about should I try something first? Should I just send it to you? [00:38:00] So I think, yeah, where the mass is so important When we're thinking about initial steps, for sure. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: That's awesome. I really love that. I think there's probably a decision making tree that we could maybe even share. I think I've seen you with that before where, we can decide based on what's presenting and that could be potentially a resource that we could share with the listeners.

Naomi Hoyer: Yeah. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: That could help them if they do get in a situation to know what should my thoughts be right now? Should I be thinking about consulting with an expert such as yourself, or should I be getting more information via additional imaging or an incisional biopsy?

Naomi Hoyer: Sure. Like stepwise okay, if this, then this, yeah cause it can feel, I think lots of people in dentistry get what I call decision making fatigue. 'cause it feels like you're having to make a decision about every tooth you're having to make a decision about everything.

So it can be challenging. 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: So much to look at, so many teeth

Naomi Hoyer: yeah. I think it can be hard.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Other things to be considered, you don't want to get in over your head if you don't have the right equipment or instrumentation. Again, we have so many other [00:39:00] episodes that we could talk about things because you don't even wanna anesthetize an animal.

Let's say if your high speed handpiece isn't working today and you have no backup. Any other thing that you can think of that you feel is a really strong important point that you want to make today for the listeners?

Naomi Hoyer: no, I think that's, the most important thing, always look and then definitely develop a relationship with somebody who can help you be a good referral partner. it's just, it is a relationship that goes both ways. Absolutely. So

to have somebody who you can work with in that way.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: I feel like all good things happen when you have good, strong relationships with other human beings that can really help. Okay. 

Naomi Hoyer: Truth for everything.

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: yeah,

Naomi Hoyer: better, I

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Dr. Hoyer, thank you so much for sharing your insight your experience and passion for veterinary dentistry, and I know your passion for education today. We really have learned a lot about when to refer patients or at least to have that in our mind. As you mentioned, there may be 250 veterinary dentists in the world. I feel like there is one near more people than [00:40:00] they think, or maybe than they know. They can go to the American Veterinary Dental College website, avdc.org and by location, find who may be nearby.

And also, I am always amazed by how many new veterinary dentists we're acquiring every single year. It's really exciting because again, more animals are going to be helped through having a stronger knowledge base around us for dentistry. All of those things are gonna help these patients hopefully get the care that they need, hopefully sooner rather than later.

At the end of each episode, I am planning on having my guests ask a question for the next guest our next guest will be also someone like yourself. More than likely a veterinary dentist.

Is there a specific question that you would love to have that veterinary dentist answer or address?

Naomi Hoyer: Yeah, so my question that I'm gonna drop to the next person is if you see a patient signalment on your schedule. Is there one patient signalment in particular that makes you go, 

"Oh,no" 

benita-altier-lvt--vts--dentistry-_1_11-25-2025_130505: Ah, that's a good one. That's a [00:41:00] good one. I love that. Okay, well that will be the question for the next dentist so that we can see what they have to say about that. Thank you for joining us on episode two of the Pawsitive Veterinary Dentistry Podcast. Be sure to subscribe and listen where you listen to podcasts. And visit me on social media platforms such as Instagram, LinkedIn, TikTok, Facebook and YouTube. We really look forward to seeing you at the next episode, so keep doing Pawsitive dentistry. Thank you so much, and thank you, Dr. Hoyer.