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Toothbrushing for Your Pet

General comments about oral hygiene for your pet:  Oral health is a function of professional therapy and continual home care. One procedure without the other will result in failure. The type and amount of home care necessary depends upon the extent of oral pathology present.  This varies from animal to animal. Some pets get away with no home management while for others, even every other day cleaning may not suffice. Success depends on the degree of plaque control you are capable of providing between professional visits. After the professional cleaning, the burden of oral health care shifts to the owner. The gold standard of home care remains brushing of the teeth.  There are many unsubstantiated claims with regard to various products available for home care.  You may end up spending money on mostly useless products that may give you a false sense of security about what you are actually doing for your pet. Nothing substitutes for regular professional cleaning and tooth brushing.

PD will progress if preventative steps are not taken. To keep the teeth healthy and plaque free, a toothbrush must be used effectively. When asked which teeth are most important to brush, the appropriate answer is “all the teeth”. It is recognized that pets are not born to willingly accept tooth brushing, some refuse it, and some owners decline to provide it. This is understandable in many situations, however, pet owners often have unreasonable expectations about what the veterinary dentist can provide from a professional cleaning “once every year or two”. If you are unable to provide the necessary homecare, then more frequent professional cleanings are encouraged.

Many young dogs and cats will have gingivitis and calculus deposits before they are one year of age.  In general, the first professional cleaning should occur by 18 months of age. Almost all pets will benefit from a professional cleaning by the time they reach two to three years of age.

Brush my what?  It is recognized that pets are not born to willingly accept tooth brushing, some refuse it, and some owners decline to provide it. This is understandable in many situations, however, pet owners often have unreasonable expectations about what the veterinary dentist can provide from a professional cleaning “once every year or two”. If you are unable to provide the necessary homecare, then more frequent professional cleanings are encouraged. If you cannot provide either frequently enough, then your pet may be destined to have periodontal disease and it’s consequences. The same holds true for humans. The bacteria really don’t care whether they’re invading a human or animal, it’s the same process.

What are we trying to accomplish with pet toothbrushing? Toothbrushing is the mechanical removal of plaque and every attempt should be made to institute daily mechanical plaque removal.   The ultimate goal is to prevent gingivitis and periodontal disease. These conditions are related to each other and are essentially infections caused by plaque bacteria.  Plaque is a fancy name for oral bacteria.  After tooth eruption, the tooth surfaces are immediately colonized by bacteria.  Plaque rapidly accumulate as layers of a slime.  Plaque will cover all tooth surfaces within 24 hours of a professional dental cleaning.  Within two weeks, minerals will begin hardening on the plaque.   This is when the films become grossly visible and we term these hardened accumulations calculus.   Calculus is essentially many, many layers of bacteria that have hardened on the tooth surface.   Periodontal diseases are the result of interactions between plaque bacteria and the immune response developed by the host.  All infections start as gingivitis.  As infections become chronic, they progress beneath the gum line and cause tooth attachment loss (bone loss) and eventually tooth loss. The main problem is chronic infection. Gingivitis and periodontal diseases are seemingly innocent and are often taken for granted.  It is the chronic immune response to the plaque which supplies damaging enzymes and inflammatory mediators to the circulation.  It is this circulating inflammation that damages the heart, blood vessels, kidneys, etc.  Toothbrushing is by far the single most effective means of removing plaque.  It will not remove mineralized calculus once it has formed.  Most dogs and cats that have not received any form of oral hygiene will have gingivitis.  The recommendation should be daily toothbrushing, if the animal will allow it.

Periodontitis is characterized by the loss of attachment (bone) below the surface and it is always preceded by gingivitis.  Because the progression of periodontal disease is advanced by subgingival bacteria, which are, in turn, derived from supragingival bacteria, it necessarily follows that meticulous supragingival plaque control (toothbrushing) can reduce the risk for the development of or progression of periodontal disease.

Limitations on what you are able to do with a toothbrush: Scientific research has demonstrated that the best human toothbrushers still miss removing plaque on up to 20% of the tooth surfaces.  No toothbrush reaches between the teeth where most periodontal disease is known to begin.  Flossing accomplishes the brushing between the teeth. Even with flossing, some surfaces are missed and it is necessary for the dentist to professionally clean what we miss. Therefore, it is daily home oral hygiene in combination with professional cleanings that control plaque and the level of oral health care. One without the other will lead to eventual patient compromise.

It is almost impossible to look at the complete inner and outer surfaces of our pet’s teeth let alone insert a toothbrush into the mouth.  Attempting to thoroughly toothbrush the inside surfaces, especially on the back teeth , is virtually impossible.  For the lower teeth alone, there isn’t room between the tongue and tooth surfaces to safely and comfortably insert a toothbrush.   It’s already established that unless you can also floss, you are missing probably the most important tooth surfaces.

It is an established fact that 90% of humans are affected by periodontal inflammation and have existing periodontal pockets of equal to or greater than 4 mm.  This pocket depth will increase with age. Although the scientific research hasn’t been done on animals, experience tells us that this is at least as bad in our pets. Another limitation of toothbrushing is that the toothbrush will only reach 1mm below the gingival margin. Therefore, toothbrushing cannot keep the established pockets that most of us have clean.

Home pet dental care (toothbrushing):

  1. Is not designed to be a substitute for regular professional cleanings.
  2. Is not, by itself, an adequate treatment for established periodontal disease.

How often do we need to brush our pet’s teeth? There are animals, especially of the larger breeds, that tend toward a natural resistance to periodontal disease.  There are people like this as well.  For these rare individuals, toothbrushing every few days may be adequate.  For most of our pets, especially if they already have established periodontal disease (pocketing), if they are not brushed at least once a day, you may be losing ground and may as well not be doing it at all.

Do I need a toothbrush or can I use gauze or another material on my finger?  It is the mechanical action of the bristles that cleans the plaque.  Other objects like gauze and cotton swabs, may be better than nothing, however, they are significantly less effective than the bristles of the brush.

Do I need a special toothbrush to brush my pet’s teeth?  The answer to this is no.  What you do need is a brush with small bristles.  Hard-bristle brushes may cause more trauma to the soft gums.  Change toothbrushes as often as you do your own.  Match the size of the brush to the size of your pet.  A human pediatric or toddler brush will often work well.  There are also different sizes of brushes that fit over your finger (finger brushes).  Finger brushes do carry some risk of injury from being bitten.  A brush with traditional bristles should eventually replace the finger brush.

Can I just place or rub the toothpaste on the gums?  No. In spite of claims that the toothpaste actually does something to kill plaque bacteria, there is no strong research to support this.  You do not need toothpaste to accomplish plaque removal.  It is the mechanical action of the toothbrush bristles that accomplishes the cleaning…not the paste.

What is the purpose of the toothpaste? The benefit of the paste is that if your pet likes the flavor of the paste, we may be able to coax them into accepting the toothbrush. Like a child, it’s much easier to get them to brush their teeth if they like the flavor of the paste.

Which toothpaste should I use:  Do not use a human toothpaste, as they contain ingredients that cause an upset stomach or toxicity (fluoride). The main goal is to have something flavorful and that your pet likes. The flavored tooth paste may help the acceptance of brushing. The second goal is to provide something that is “safe” for your pet to ingest. This is an unregulated industry and many products contain ingredients that are not known and may be harmful. We recommend using brands that have withstood the test of time on the safety issue. We generally recommend the C.E.T brand (poultry, beef, vanilla flavors). Tuna water may also be used for cats.

Where should I focus toothbrushing: While brushing all tooth areas would be ideal, this is rarely accomplished. The inner surfaces of the teeth often have less plaque and calculus and not areas on which to focus early efforts.  For most pets, the tongue does a relatively good job of keeping this surface clean and most pets will not tolerate action on this side.  Eventually, you may be able to work-up to these surfaces on your pet. The areas of primary concern are the outside (labial) surfaces of the cheek teeth (premolars and molars), canine teeth and incisors.  If you only have seconds and need to know where best to focus your efforts, in general, attempt to brush the upper canine and cheek teeth.

Teaching your pet to tolerate tooth brushing: In general, dogs will be easier to use a tooth brush with than cats. Younger animals are more accepting than adults, but all can become accustomed to the routine. The results are worth your time and energy.  Key points are to go slow (take baby steps) and be patient as each step of the training process may take weeks.  Most dogs will eventually accept brushing.  A pet that resists brushing may be doing so because they have painful areas in the mouth. Try to make tooth brushing a pleasurable experience by following the session with praise, a treat, a game or play period. You might begin by using a good tasting substance (flavored toothpaste (C.E.T. brand…poultry, beef flavors) or tuna water for cats) as a treat several times a day on your finger. Over a number of days, progress to rubbing your finger at the gum line as your pet licks the treat. Build up to spending more seconds and minutes in the mouth and over the full range of teeth.  Eventually replace the treat on your finger with a soft bristled tooth brush. Special pet brushes are available; however, pediatric or human brushes also do a good job…whatever works adequately for you and your pet.

Toothbrushing techniques:  For dogs, it is sometimes easier to access the teeth on the side of the mouth with the lips closed.  Gently pull the commissure of the lips backwards and insert the brush.  Bristles are angled at a 45 degree angle to the gum-line and moved back and forth or in small circular motions.  Advance the brush forward in the mouth.  Slight angle changes may accommodate the changes in tooth surfaces.  Some pets accept a toy inserted into the front of the mouth.  This can aid in holding the mouth open and accessing the lower teeth.  Attempt brushing motions for 30-60 seconds on each side.

For cats, it may be best to massage/brush in a forward to back direction as this simulates their natural behavior when they rub against a person or object, inconspicuously marking the property with their saliva.

Tooth brushing and home care for your cat: Acceptance of tooth brushing is a little more difficult with cats than dogs.  Brushing can be accomplished in most cats.  A very gradual (and gentle) approach that may take 1-2 months is often necessary.  As for dogs, teach to accept the paste as a treat off your finger and gradually work up to licking the treat off a small tooth brush (cat finger brushes are best).  Work up to spending more & more time in the mouth and then brushing back and forth.  An excellent video on brushing teeth in cats can be viewed on the Cornell University Feline Health Center website: www.vet.cornell.edu/fhc/   go to feline health videos, then “brushing your cats teeth”.

Complete oral hygiene:  Remember that good oral hygiene requires a combination of “home care” as well as professional dental cleanings. The frequency necessary for professional dental cleaning will depend upon the individual patient’s needs.  A general recommendation is to have a professional cleaning performed every 12 months.  Some individuals might not require a cleaning once a year, however, especially with established periodontal disease, once every 12 months may not be near enough to keep infection under control.

Pet Dental Diets, Treats & Antiseptics

Dental diets, dental treats and chewing exercise:  There is no solid research that supports many of the dental health claims made by many manufacturers of diets, treats and chew objects for pets.  The masticatory forces on food can create frictional forces that are physically able to prevent accumulation of plaque, and even remove it. Where this beneficial effect occurs is at the incisal or cusp areas of the teeth. These same forces, however, are less effective at the gingival margin where the plaque and calculus accumulations are most important. Therefore, the natural cleaning forces of mastication, and the food type, are limited to the regions of the tooth that are at less risk for periodontal disease.

It is important to remember the evolutionary function of carnivores…they are meat eaters.  The function of carnivore oral behavior is to grasp, pull and hold prey. This is followed by cutting and tearing meat before crushing and gulping. Carnivore teeth are not designed to chew bones or other objects harder than the teeth.  Fractured teeth are a problem of epidemic proportions in our domestic canine population. Starving wild animals may elect to chew bones, however, they also can break their teeth which places them at a survival disadvantage (survival of the fittest). Dental treats and chew objects should be considered as only part of preventative dental health care. In conjunction with daily tooth brushing, dental diets and regular professional cleanings, toys and treats can play an important part of oral health care maintenance.

Strictly avoid bones (cooked or uncooked), cow hoofs, pig ears, hard & thick rawhides, plastic or nylon bones, plastic bottles, any antlers and large ice cubes. Tennis balls and other objects with abrasive surfaces should also be avoided as these have a sandpaper like effect on tooth structure that damages the tooth and may expose the pulp.  The flatter, softer rawhide chews have been shown to be safe and effective in reducing the rate of plaque accumulation.  C.E.T. Hextra rawhide chews contain chlorhexidine which enhances their effectiveness.  Kong toys are of a firm rubber design, come in a variety of shapes & sizes and some allow you to place cheese or peanut butter inside to improve acceptance. For cats, C.E.T. Oral Hygiene Chews for cats contain products that help provide antibacterial effects in the mouth.

Take note: you must always monitor your pet when they are chewing on anything.  Verify they’re not gagging, trying to ingest too much at one time or attempting to eat an inedible product. Please refer to Animal Dentistry & Oral Surgery’s article on Safe and Appropriate chew objects.  Using products with the Veterinary Oral Health Council (VOHC) seal of acceptance is recommended as these products have successfully met strict pre-set requirements for veterinary dental efficacy and safety.

Dental chew objects do not replace toothbrushing. They are generally inadequate in removing plaque in most pets and entirely inadequate in controlling plaque in areas of already established periodontal disease (pocketing).

How do pet dental friendly diets work and which ones are available?  History proves that improved nutrition is a major reason pets live longer and lead healthier lives. From a nutritional standpoint with pet foods, it is a wise decision to purchase the best food you can afford.  Dry foods are considered a little better than canned foods because they have some abrasive activity which helps remove plaque from the crowns of the teeth.  Soft foods will generally result in greater plaque accumulation than hard diets. Hard diets are less likely than canned foods to become packed between teeth and in the gingival crevices.  However, even on the harder diets, plaque and calculus does accumulate and periodontal disease is evident. Several commercial foods have received the respected VOHC seal of approval for demonstrating product effectiveness and safety. Dental diets can effectively reduce some plaque and calculus accumulation, but do not eliminate it. Hill’s prescription diet Canine and Feline t/d® and Science Diet Oral Care® are both balanced nutritionally and have a good “mesh type” effect.  Dietary fibers are arranged more parallel than many of the dry foods, and the kibble is larger, forcing the teeth to penetrate the kibble rather than shattering it, thus providing additional abrasive action to help keep the teeth cleaner above the gum line.  Eukanuba Dental Defense Diet, Friskies Dental Diet and Royal Canin Diets contain a chemical coating (polyphosphates) on their kibble. This chemical is activated in the mouth and safely delays calculus (tarter) build-up.  It is important to understand that dental diets have limited effectiveness and do not replace the need for tooth brushing and professional cleanings. This is especially important to appreciate for those pets that already have PD.

Pet Drinking Water Additives: There is relatively little scientific research to support the claims made by many manufacturers of water additives and oral sprays for adequate plaque control.  Where the desire is to make “evidence based” recommendations, the evidence for support of these products is low.  There are serious health risks associated with some of these products that are actually available over the counter.  Some of the sweeteners (Xylitol) used are known toxins for animals. It is recommended that additives only be used with your veterinarians’ direction. Oral bacteria produce gases which account for the halitosis (bad breath) associated with gum disease.  Various products are designed to reduce this oral odor, however, they may be doing nothing towards actually eliminating the bacteria (cause of the problem). Healthy Mouth® Anti-plaque Water Additive is the only VOHC approved water additive.

Oral Antiseptic Products: These are chemical plaque control products.  The only ones in this category worth mentioning are those containing 0.12% Chlorhexidine gluconate (CHX). CHX products are excellent for patients with established periodontal disease. CHX is the gold standard oral antiseptic and there is nothing close to comparing with it. CHX products are generally prescription products that should only be used under the direction of a veterinarian.  Antiseptic solutions are designed for twice a day usage and the gold standard ingredient is 0.12% Chlorhexidine gluconate. The rinse is applied by squirting a small amount inside the cheek on either side of the mouth. CHX is inactivated by organic matter.  Although CHX can stain the teeth, the staining is usually of the plaque and calculus, and is removable.  This is the most effective antibacterial (also antiviral) agent that can be utilized in the mouth and it works by binding to the teeth and other oral tissues. It is slowly released into the oral cavity over a 12 hour period.  Chlorhexidine rinses are also good for cats, however, some tolerate the flavor & others do not.

For the best results, use the chemical plaque control (CHX rinsing) to augment the effect of mechanical plaque removal (toothbrushing).

Several products contain zinc ascorbate. This has antiseptic properties, but also benefits gingival health by promoting collagen formation and epithelialization of ulcerated tissues.  Maxiguard™ oral formula (Addison Biological Laboratory) is an example of this type of product. It can also beneficial after oral surgery for its antimicrobial and healing promoting effects.

Safe and Appropriate Chew Toys for Dogs

Fractured pet teeth are one of the more common dental problems encountered by veterinary dentists. Broken teeth, more often than not, have exposed pulp tissues that subsequently become infected.  Just like for humans, apical infection (apical periodontitis, dental “abscesses”) will occur in a matter of time. They are painful and cause exposure of the body to chronic bacteria infusion and inflammation. In most cases, the problem is caused by dogs being allowed to chew on objects that are just too hard for their teeth. These objects may actually be harder than the teeth.  It is important to remember the evolutionary function of carnivores…they are meat eaters. The function of carnivore oral behavior is to grasp, pull and hold prey. This is followed by cutting and tearing meat before crushing and gulping. Carnivore teeth are not designed to chew bones or other objects harder than the teeth.  Starving wild animals often have only bones to eat, however, they also break their teeth, which places them at a survival disadvantage (survival of the fittest). Wild carnivores that do eat bones are usually doing so from freshly killed prey.  Fresh bones are softer, however, they still can lead to traumatized and fracture teeth. Dental treats and chew objects should be considered as only part of preventative dental health care (please refer to information on dental diets, chews and antiseptics).  In conjunction with daily tooth brushing, dental diets and regular professional cleanings, toys and treats can play an important part of oral health care maintenance.

Strictly avoid bones (cooked or uncooked), cow hoofs, pig ears, hard & thick rawhides, plastic or nylon bones, and large ice cubes. Tennis balls and other objects with abrasive surfaces should also be avoided as these have a sandpaper-like effect on tooth structure that damages and may expose the pulp. The flatter, softer rawhide chews have been shown to be safe and effective in reducing the rate of plaque accumulation. C.E.T. Hextra rawhide chews contain Chlorhexidine which enhances their effectiveness.

When trying to select safe chew objects for your pet, there are two good approaches:

  1. General rules of thumb.
  2. Use products approved by the Veterinary Oral Health Council (VOHC)

A. Rules of Thumb

  1. You want to be able to indent the surface with your finger nail.  Surface has some “give” to it.
  2. “Knee Cap Rule”: If you hit your self in the knee with the object and it hurts, it’s probably too hard/heavy for your dog.
  3. “Hammer Rule”: If you can drive a nail with the product, don’t allow your dog to chew on it.
  4. Also avoid objects with abrasive surfaces like Tennis Balls and Frisbees.
  5. If you cannot flex or break the product with your bare hands, it’s probably best to avoid it.
  6. Please take note: you should always monitor your pet when they are chewing on anything.  Verify they’re not gagging, trying to ingest too much at one time or attempting to eat an inedible product.

B. VOHC approved products
Although not all safe products have VOHC approval, using products with the VOHC seal of acceptance is recommended as these products have successfully met pre-set requirements for veterinary dental efficacy and safety.  A complete list of VOHC approved products can be accessed at www.vohc.org.

Anesthesia Free Dental Cleanings

At ADOS we are more frequently encountering dogs that have had “Anesthesia-Free Dental Cleanings” or what has been termed “Non-professional Dental Scaling” (NPDS).  The alternative is professional dental scaling that require general anesthesia.   There are a few reasons for this notable increase.  This is primarily the result of more owners being aware of the importance of oral health care for their pets.  These owners also have natural concerns about the risks of anesthesia and the associated costs.  Unfortunately, Anesthesia Free Dental Cleaning has been marketed as an attractive alternative that touts the same benefits as professional scaling without the cost and risks.  By definition, a complete and comprehensive oral exam includes a complete visualization of all structures, periodontal probing and dental X-Rays.  In spite of claims some individuals make, it is technically impossible for anyone to perform a “complete, comprehensive and thorough” oral assessment on our companion animal patients without the assistance of general anesthesia.  As a corollary, proper treatment of any oral problem is even less possible to perform in a conscious patient.

Unfortunately, without the benefit of general anesthesia, pets most often do not receive the proper and timely preventative (maintenance) care, diagnosis and treatment of oral problems.  It is acceptable for well meaning clients to decline professional treatment because of their fear of anesthesia or if they cannot afford it, however, it is another thing to be fooled by the marketing of untrained individuals that target this fear and offer an alternative that is “just as good”.   This is a service whose marketing sounds appealing and logical on the surface, however, it promises a lot more than can be delivered.  Non-Anesthetic Dentistry is essentially a cosmetic procedure that addresses only the visible surfaces of only some of the pet’s teeth.  What results are pets that are not receiving thorough preventative care and some have serious dental problems that go undiagnosed and/or are improperly treated.

As previously noted, not all surfaces of a pet’s teeth are even visible in a conscious patient.  The palatal and lingual aspects of the dentition are simply not visible on an awake patient.  Periodontal disease affects surfaces for 360 degrees around the teeth. Even in human patients, most periodontal infections start in locations between teeth where the toothbrush does not reach.  The bacteria that cause periodontal disease are especially biologically active subgingivally (below the gumline).  Subgingival biofilm bacteria and infection (if developed) is not addressed with Non-Anesthetic Dentistry and a false sense of accomplishment is conveyed. These pets continue to be affected for years with chronic oral infection (and associated inflammation) which progresses to the point of potential pain, tissue loss and eventually tooth loss.  When infections are finally recognized, the patients are usually older, often have additional health related problems that increase the risks of anesthesia.  Instead of treatment being an elective procedure on a relatively healthy patient, there is often urgency to treating the problem on a less healthy patient.  The problems become not only more urgent to treat, but treatment costs are then often greater.

Although there is always some degree of inherent risk, most major anesthetic risks are associated with two things: 1) the general health of the patient. (When appropriate preanesthetic health screening have been performed, the risks associated with anesthetic management are markedly lower.  This same holds true for most of our patients with other existing health related problems.  The more we know the details of your pet’s health, the safer we can deliver anesthesia and effective oral health care.)  2) the level of training, knowledge, caring and skills of those individuals administering and monitoring the anesthesia itself. (this of utmost importance for anesthetic safety.  This arena of care is behind the scenes, and is not the same in every veterinary (or human) facility.  It’s what goes on behind the scenes that counts.  ADOS maintains among the highest standards for anesthesia and anesthesia related care.  At ADOS, we are located within The Life Centre campus and we have the benefit of collaborative expertise, knowledge and support of other AVMA board-certified specialists.  This includes cardiology, internal medicine, emergency/critical care, ophthalmology, oncology, and surgery.)  Please refer to the preanesthetic risk assessment page on our website (animaldentalspecialist.com) for information on proper preanesthetic risk assessment and required testing.

In California, a recent (2012) case of a fractured jaw led to a ruling against the party preforming anesthesia “Anesthesia Free Dentistry”.  Subsequent to this ruling, the Board of Veterinary Medicine of the State of New Jersey banned Non-professional Dental Scaling as practicing veterinary medicine without a license. Veterinarians who support individuals involved with “Anesthesia-Free Dentistry” should consider the professional, ethical and potential legal considerations.

The following is the American Veterinary Dental College (AVDC) Position Paper on Companion Animal Dental Scaling Without Anesthesia

In the United States and Canada, only licensed veterinarians can practice veterinary medicine. Veterinary medicine includes veterinary surgery, medicine and dentistry. Anyone providing dental services other than a licensed veterinarian, or a supervised and trained veterinary technician, is practicing veterinary medicine without a license and shall be subject to criminal charges.  Recently (2012, in the state of California) an individual who was performing anesthesia free dental cleanings on pets, was convicted of practicing veterinary medicine without a license.

This position statement addresses dental scaling procedures performed on pets without anesthesia, often by individuals untrained in veterinary dental techniques. Although the term Anesthesia-Free Dentistry has been used in this context, AVDC prefers to use the more accurate term Non-Professional Dental Scaling (NPDS) to describe this combination.

Owners of pets naturally are concerned when anesthesia is required for their pet. However, performing NPDS on an unanesthetized pet is inappropriate for the following reasons:

1. Dental tartar is firmly adhered to the surface of the teeth. Scaling to remove tartar is accomplished using ultrasonic and sonic power scalers, plus hand instruments that must have a sharp working edge to be used effectively. Even slight head movement by the patient could result in injury to the oral tissues of the patient, and the operator may be bitten when the patient reacts.

2. Professional dental scaling includes scaling the surfaces of the teeth both above and below the gingival margin (gum line), followed by dental polishing. The most critical part of a dental scaling procedure is scaling the tooth surfaces that are within the gingival pocket (the subgingival space between the gum and the root), where periodontal disease is active. Because the patient cooperates, dental scaling of human teeth performed by a professional trained in the procedures can be completed successfully without anesthesia. However, access to the subgingival area of every tooth is impossible in an unanesthetized canine or feline patient. Removal of dental tartar on the visible surfaces of the teeth has little effect on a pet’s health, and provides a false sense of accomplishment. The effect is purely cosmetic.

3. Inhalation anesthesia using a cuffed endotracheal tube provides three important advantages… the cooperation of the patient with a procedure it does not understand, elimination of pain resulting from examination and treatment of affected dental tissues during the procedure, and protection of the airway and lungs from accidental aspiration.

4. A complete oral examination, which is an important part of a professional dental scaling procedure, is not possible in an unanesthetized patient. The surfaces of the teeth facing the tongue cannot be examined, and areas of disease and discomfort are likely to be missed.

5. Hand scaling alone (without polishing) can make the tooth surface even more plaque retentive.  The metal scaler is harder than the surface of the tooth and it can microscopically etch the surface. These microetchings create a rougher and larger surface area where plaque bacteria can attach to the tooth.  This actually accelerates plaque (bacteria) and calculus reaccumulation and fuels gingivitis and periodontitis.

Safe use of an anesthetic or sedative in a dog or cat requires evaluation of the general health and size of the patient to determine the appropriate drug and dose, and continual monitoring of the patient. Veterinarians are trained in all of these procedures. Prescribing or administering anesthetic or sedative drugs by a non-veterinarian can be very dangerous, and is illegal. Although anesthesia will never be 100% risk-free, modern anesthetic and patient evaluation techniques used in veterinary hospitals minimize the risks, and millions of dental scaling procedures are safely performed each year in veterinary hospitals.

To minimize the need for professional dental scaling procedures and to maintain optimal oral health, the AVDC recommends daily dental home care from an early age. This should include brushing or use of other effective techniques to retard accumulation of dental plaque, such as dental diets and chew materials. This, combined with periodic examination of the patient by a veterinarian and with dental scaling under anesthesia when indicated, will optimize life-long oral health for dogs and cats.

For general information on performance of dental procedures on veterinary patients, please read the AVDC Position Statement on Veterinary Dental Healthcare Providers, which is available on the AVDC web site (www.AVDC.org). Please feel free to also visit a website put together by the AVDC Public Relations Committee (www.AVDC.org/AFD/) for more helpful information for veterinarians and pet owners. For information on effective oral hygiene products for dogs and cats, visit the Veterinary Oral Health Council web site (www.VOHC.org).

The Importance of Veterinary Dental Radiology

Dental radiology is the core diagnostic modality for veterinary dental care.  Trying to diagnose and treat dental disease without radiographs is like trying to treat ear disease without an otoscope, or diabetes mellitus without blood glucose measurements.

If a practice is not currently taking dental radiographs, they are sending many, if not most, of their patients home with painful dental problems. Unfortunately, the pets seem to act fine, they eat well according to the owners, and rarely do they show any overt sign that they are in pain. Many owners assume that because there is no obvious pain, there is no pathology.  Many veterinarians assume that unless a tooth is loose, it does not require treatment.  Nothing could be further from the truth.  The accompanying dental radiographs all illustrate cases where non-mobile teeth in apparently normal patients are associated with significant pathology.  When these types of problems are found and addressed, the patients typically act “years younger”, according to the owners.  If you start taking dental radiographs and treating the hidden disease in your patients, you will likely find that the majority of your positive client comments are generated from your dental cases.

The cost for implementing dental radiology is minimal.  New dental X-ray machines are available for around $3500. I would recommend avoiding older human dental X-ray units, as there can be issues with inconsistent exposure times and radiation scatter. An additional $300 gets you a chairside developing tank, film, film clips, and chemistry. Most practices will be happiest using D-speed X-ray film, which provides high detail and is more forgiving of errors in exposure and processing. To save time, a small X-ray view box should be located next to the chairside developer. You should be able to pay for your entire dental radiology investment of around $4000 in one month. You will realize income from the dental radiographs, as well as from the treatment of otherwise hidden pathology. What other area of veterinary medicine provides this kind of return?

A more recent advancement in dental radiology is the availability of digital systems, which eliminate the need for film and chemistry. Digital systems typically range from $7000 to $16,000 in cost, and represent the wave of the future for many practices. Images are organized in a database, and must be backed up regularly to prevent loss of patient records. Some digital imaging software allows for the easy importing of high-quality pictures, printing of client letters with radiographs and pictures, and displaying images from the pet on a large screen in the exam room. Owners love seeing pictures and radiographs from their pet!

The idea of dental radiology is a new one for many practitioners and their clients. You will have to invest a few hours of time and staff training to achieve good results, but the rewards in improved patient health, client satisfaction, and practice revenue will be enormous.  I have yet to find one practice, regardless of size, location, or socioeconomic status of their clientele that has failed to successfully implement dental radiology if they tried it.

Fractured Pet Teeth

Fractured teeth are common in dogs and cats and usually caused by either trauma to the head or from pets chewing on inappropriately hard objects such as bones. Often fractured teeth go unnoticed by the owners unless they directly observe the injury when it takes place. Veterinarians and technicians often identify fractured teeth incidentally while performing routine oral examinations.

Physical and radiographic evaluations are essential to determine the best treatment option for an individual fractured tooth. Conscious oral exams performed in the exam room are of limited value. A complete, more thorough evaluation must be performed while the patient is anesthetized.

Once the patient is anesthetized, physical evaluation can be performed and dental radiographs obtained. A pointed dental explorer is used to probe the dental tissues for loose fragments, cracks, and to assess whether the fracture has exposed the pulp chamber (complicated fracture). A periodontal probe is used to evaluate the extent to which a slab fracture extends below the gingival margin. Transillumination can help reveal vertical fractures as well as determine tooth vitality. A vital tooth will have a translucent appearance while a non-vital tooth may appear opaque. Dental radiographs are necessary to complete any tooth evaluations, and to directly assess whether or not there are root fractures or if an apical periodontitis is present.

Enamel Fractures: A simple crown fracture involving just the enamel may only require smoothing the enamel with a fine diamond bur in a water-cooled, high-speed hand piece.

Uncomplicated Crown Fractures: These are defined as fractures that include both enamel and dentin layers of the tooth, however, there is no pulp exposure. Treatment goals are to protect and restore the tooth by using layers of bonded dental sealants and composites. After the tooth is smoothed and the enamel beveled, the fractured tooth is cleaned, polished with flour of pumice, etched, and treated with a bonded dental sealant. A composite filling material can then be placed over the fracture to restore the tooth and provide an additional protective layer. Some uncomplicated fractures may actually occur at a depth where a “near pulp exposure” has occurred (pink spot in the dentin over the area of the pulp chamber). For treatment, an additional protective layer for the pulp may be indicated. Once the near pulp exposure is treated, the fractured tooth can be restored as previously described. Even uncomplicated crown fractures may traumatize the pulp to the degree that it eventually becomes non-vital (necrotic). Follow-up radiographs are indicated.

Complicated Crown Fractures: These are defined as fractures that extend into and expose the pulp. If the pulp exposure is recent (24-48 hours since exposure in a mature dog, or up to 2 weeks exposure in a dog less than 18 months of age), vital pulp therapy (VPT, partial pulpectomy, and directly medicating the pulp) may be a treatment option. After performing VPT, the tooth is restored with adhesives and composites as described above. If the fractured tooth with pulp exposure does not meet the criteria for partial pulpectomy and pulp capping, then root canal therapy is indicated before restoring the fractured tooth. Any non-vital tooth will become infected. It is only a matter of time. Because of this, from the patient’s perspective, the “wait and see” treatment option approach is incorrect and inappropriate. The pulp must be removed and is done so by either extracting the tooth or having a root canal procedure performed.

Crown-Root Fractures: This type of fracture is often encountered with the classical “slab-fracture” of the upper 4th premolar in dogs. In these cases, the root fracture component disrupts the normal gingival/periodontal attachment around the tooth. This predisposes to focal, chronic periodontitis problems. Therefore, treatment decisions for the tooth need to reflect consideration for the ongoing periodontal health of the tooth.

Root Fractures: These may destabilize the tooth and the crown may be loose. Often, however, root fractures are discovered incidentally on intra-oral radiographs. In most cases, endodontic complications will occur and the treatment option of choice is removal of both the crown and root segments.

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Antimicrobial Therapy for Veterinary Dental and Oral Surgical Procedures

The use of antimicrobial drug (AMD) therapy by veterinarians after oral/dental procedures is very common practice. In most cases this use is not necessary. A major concern is the emergence, spread and high prevalence of multidrug-resistant (MDR) pathogens. This is believed to be associated with the frequent use of AMDs(1). The use of AMDs provides selective pressure on MDR pathogens to evolve. The excessive and frequent use of AMDs in companion animals may be a risk factor for MDR zoonotic infections in people including veterinary hospital personnel(1). Stewardship practices for AMD use in companion animals is needed to slow the emergence and spread of MDR bacteria among humans and animals(1). It is recommended that every veterinary medical record include a justification for AMD use in an animal(2).

Important General Principles for AMD use for Veterinary Dentistry and Oral Surgery:

  1. Plaque is a biofilm. It must be remembered that for most oral infections (especially periodontal disease) you are dealing with organisms in a biofilm environment and not in their planktonic forms. The biofilm protects organisms from AMD attack. Concentrations of antibiotics may have to be up to 1000 higher to be effective against biofilms. There are multiple, separate biofilm environments within the oral cavity. The supragingival and subgingival environments harbor differing biofilms. Due to the biofilm environment and to the number and variety of oral organisms, culture and sensitivity testing are usually unreliable and not feasible.
  2. AMDs should never be used as a monotherapy. Although periodontal disease is caused by bacteria, AMDs should not be the primary treatment strategy(3). Therefore, the mechanical disruption of plaque (dental scaling/polishing) prior to local or systemic AMD delivery is needed to obtain effective results. To do otherwise is an inappropriate use of AMDs and selective pressure for MDR is increased. The days of “pulse antibiotic” therapy are over. This is an inappropriate use of antibiotics.
  3. Systemic antibiotics (Ab) enter periodontal pockets via crevicular fluid flow and oral infection sites via secretion in the saliva. These are round-about means of delivery. Crevicular fluid exchange is 40X/hour and is increased when inflammation exists. Therefore, the Ab contact time is markedly limited.
  4. The “gold standard” for prevention and control of periodontal disease remains professional supragingival and subgingival dental scaling followed by daily toothbrushing. Oral hygiene at home may be enhanced by utilizing special diets, chew objects and antiseptic rinses; however, these methods are not as effective as toothbrushing and are not designed to replace toothbrushing.
  5. The long held belief that oral infections (particularly endodontically treated teeth) result in systemic illness or cause disease processes in distant locations, does not have scientific merit(4). This concept often drives recommendations for systemic AMD use. Therefore, most prophylactic AMD use in dentistry has no scientific basis.
  6. Because of the excellent blood supply, wound healing in the oral cavity is rapid and uncomplicated. Therefore, infectious complications are uncommon.
  7. Antibiotics are recommended for patients with existing medical conditions (EMC). Patients with compromised immune systems may be at higher risk for anticipated bacteremias progressing to overwhelming septicemias. These patients include patients undergoing chemotherapy, have FIV and/or FeLV infections, have poorly controlled diabetes or have other debilitating diseases(4,5).
  8. Oral surgery cannot be considered sterile. Most oral surgeries are either clean-contaminated or contaminated (dirty).
  9. Minor lacerations rarely require AMDs. Deeper and/or more heavily contaminated wounds may benefit from AMDs.
  10. Antibiotics are indicated for most patients with local and systemic signs of established infection (i.e. pain, swelling, pus formation, lymphadenopathy and elevated WBC).
  11. There is currently no scientific support for the previously held belief that there is an association between bacterial endocarditis and either dental/oral surgical procedures or oral infections in dogs(5).
  12. The American Heart Association only recommends antibiotic prophylaxis for dental procedures as being reasonable for patients with prosthetic cardiac valves, previous infectious endocarditis and some forms of repaired congenital heart diseases(6).
  13. Postoperative oral antibiotics are not routinely recommended for patients undergoing extractions. A perioperative dose may be considered for patients requiring multiple surgical extractions with osectomy, those with severe, generalized periodontitis, and/or patients with medical conditions which might impair their ability to clear anticipated bacteremia(5).
  14. In some patients with severe periodontitis, antibiotic use for a few days prior to the procedure may be indicated to reduce periodontal inflammation(5).
  15. Unless there are indications because a patient has EMC, there is no justification for using prophylactic antibiotics for patients undergoing periodontal surgery(5).
  16. Locally delivered AMDs may be very beneficial. 0.12% chlorhexidine gluconate is considered the “gold standard” of topical AMDs. This agent binds to teeth, oral mucosa, pellicle and saliva (high substantivity). It binds to and damages bacterial cell membranes (bacteriocidal).

References:

  1. Baker, S.A., Van-Balen, J., et al. Antimicrobial drug use in dogs prior to admission to a veterinary teaching hospital. JAVMA, 2012;241.
  2. AVMA website. Guidelines of veterinary prescription drugs.
  3. Radice, M., Reiter, A. Evaluation of Subgingival Bacteria in the Dog and Susceptibility to commonly used Antibiotics. J. Vet. Dent, 2006;23.
  4. Tong, Darryl C. Antibiotic Prophylaxis in Dentistry. J. Am. Dental Assoc. 2000;131.
  5. Verstraete, Frank JM. & Lommer, Milinda J. (editors). Oral and Maxillofacial Surgery in Dogs and Cats: Antibiotic use in oral surgery. Saunders-Elsevier 2012.
  6. Wilson, W., et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. 2007;116.

My Pet is old or has an underlying medical condition and I am afraid of anesthesia

At Animal Dentistry & Oral Surgery we are pet lovers, so we understand your concern. We always indicate that there are risks associated with anesthesia, which is why it is important to evaluate a pet fully prior to anesthesia to determine if an anesthetic procedure will be safe for them and that the risk are warranted to address the level of disease that is present. When you choose a highly experienced veterinary dentist, you can be assured your pet is in the best of hands.

Pre-operative testing including a Complete Blood Count (CBC) and Biochemistry Profile will help us to determine if there are issues that may be are a concern. A urinalysis and thyroid evaluation may also be recommended. Further testing depending on the results of a CBC or biochemistry profile may be recommended prior to anesthesia.

Depending on the age of the pet and if a heart murmur or arrhythmia is noted, an evaluation by a cardiologist is recommended to determine if the heart disease/issues will pose a higher risk of a complication intra or post operatively.

Your pet’s safety under anesthesia is our priority and we take precautions to minimize the risks of serious complications under anesthesia.  As board certified veterinary dentists, we monitor each pet very closely under anesthesia and a registered/licensed technician is monitoring your pet’s vital parameters at all times. This dedicated technician is not involved in the dental procedure at the same time that they are monitoring the patient under anesthesia, because their priority is to the patient’s safety.

My Pet’s Veterinarian says that they have bad / diseased teeth, what should I do?

If your veterinarian says your dog or cat’s teeth are bad or diseased, it often means that your pet has significant periodontal disease and an evaluation under anesthesia including intra-oral radiographs would be recommended to evaluate the teeth further.

This is a circumstance in which you should ask your veterinarian to refer you to a board certified veterinary dentist. Often, we have a wide range of treatment options available that will best meet your dog or cat’s individual needs and in certain cases we may be able to save teeth that otherwise would be extracted.

What if my dog or cat has bad breath

Bad “Dog Breath” or “Kitty Breath” is a sign of infection and periodontal disease in your pet’s mouth. Typically the worse the breath smells the worse the disease. This is a sign you should bring your pet in for a complete oral health exam and dental cleaning.

Once your pet’s teeth have been cleaned and any diseased teeth have been addressed, home care will be important in maintaining better smelling breath. Plaque (the film that forms on our teeth) is also present in our pet’s mouths. This is a bacterial biofilm and it is the bacterial waste products that cause oral malodor.  Brushing disrupts the biofilm and removes the bacteria. This helps keep bad breath under control, just as it does for our own breath.

It is possible that sometimes what we think is a bad smell coming from the mouth is not. Odors can come from further down the digestive tract, from the respiratory tract, ears or skin. If the problem persists after a dentistry procedure it is possible that further evaluations may be necessary.