5 Nov

Dentistry home care: what should I recommend?

Ana Nemec considers what advice vets should offer owners on oral care at home to maximise their pets' dental health.

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Ana Nemec

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Dentistry home care: what should I recommend?

Figure 1. Annual professional oral care is recommended, although the individual animal’s needs should be taken into consideration. In an anaesthetised animal a detailed oral/dental examination is performed and dental radiographs obtained to accurately diagnose any disease and plan treatment.

ABSTRACT

Periodontal diseases are the most common, usually chronic, inflammatory diseases of dogs and cats, caused by bacteria in the dental plaque. Plaque starts to form in minutes on clean enamel surfaces and, once mature, is highly organised and, hence, well protected from host response and antimicrobials. To prevent periodontal diseases, therefore, plaque must be disrupted as often as possible by regular (annual) professional oral care visits to the vet and daily oral home care.

The gold standard oral home care in animals is active mechanical removal of plaque by daily tooth brushing, which can be effectively supplemented (or in non-cooperative animals, at least partially replaced) by dental diets or daily addition of certain chews or edible treats. Particular oral rinses, sprays, gels, water additives, wipes for teeth and dental sealants have also been shown to be effective in reducing plaque or calculus accumulation and gingivitis. Due to a vast array of products available, vets should seek evidence a product they wish to recommend to the client is safe to be used in animals and scientifically proven to be effective in reducing plaque or calculus accumulation and gingivitis.

Periodontal diseases are the most common, usually chronic, inflammatory canine and feline conditions (DeBowes, 2010) as they affect the majority of the older population of dogs – especially smaller breeds (Harvey et al, 1994; Marshall et al, 2014) and most cats (Girard et al, 2009).

Periodontal diseases are infectious, caused by bacteria in the dental plaque (biofilm on tooth surfaces), which, once mature, is highly organised and, hence, also resistant to host response and antimicrobials (Jakubovics and Kolenbrander, 2010). Plaque is subsequently mineralised to form dental calculus (Clarke, 1999; Jin and Yip, 2002; Borah et al, 2014).

The exact role of calculus in the development of periodontal diseases is unclear, but due to its rough surface, enhances plaque accumulation. Plaque bacteria causes inflammation of the gingiva (gingivitis), which may persist for years, but is completely reversible with plaque removal. However, if left untreated, in most cases, it causes irreversible destruction of the periodontium (periodontitis) and may lead to loss of tooth function and, ultimately, tooth loss (Wolf et al, 2005; DeBowes, 2010).

Without oral home care, it has been described periodontitis develops very early in the life of some dog breeds (Marshall et al, 2014), hence, oral home care should be instituted early and continued throughout the animal’s life with regular professional oral care to ensure periodontal health.

Professional oral care

The frequency of visits to the vet to receive professional oral care (Figure 1) depends on the animal’s disease stage and rate of progression, as well as its oral home care (DeBowes, 2010). In some cases, professional oral care may be suggested as often as twice yearly (Marshall et al, 2014). The purpose of this is to determine the extent and severity of periodontal (and any other oral/dental) disease by means of a detailed oral/dental examination and dental radiography, and provide appropriate treatment (DeBowes, 2010).

Treatment always starts with professional dental cleaning that includes supragingival and subgingival scaling and polishing to remove plaque and calculus (DeBowes, 2010; AVDC Nomenclature Committee, 2016). In cases of advanced periodontal disease, therapy is provided as indicated, where dental cleaning is followed by periodontal debridement, root planing, extractions or any other surgical procedures, as indicated. All these procedures can only be accurately performed under general anaesthesia (DeBowes, 2010; EVDS, 2013; AVDC Nomenclature Committee, 2016).

Oral home care measures

Without oral home care, the benefits of professional oral care are short-lived as bacteria start to colonise clean enamel surfaces in minutes (Jin and Yip, 2002; Jakubovics and Kolenbrander, 2010). Oral hygiene measures by pet owners are, therefore, aimed at controlling dental deposit accumulation (AVDC Nomenclature Committee, 2016) as much and as often as possible (Jakubovics and Kolenbrander, 2010). This is not a substitute for regular professional oral care as it does not remove existing dental deposits; however, the intervals between visits to the vets can be extended (Ray and Eubanks, 2009), thereby reducing owner costs.

Figure 2. Professional oral care is recommended annually, although an individual animal’s needs should be taken into consideration. With the animal under general anaesthesia, detailed oral/dental examination is performed and dental radiographs obtained to accurately diagnose oral/dental disease and plan treatment. Oral/dental treatment always starts with professional dental cleaning. Image: David Černec
Figure 2. Professional oral care is recommended annually, although an individual animal’s needs should be taken into consideration. With the animal under general anaesthesia, detailed oral/dental examination is performed and dental radiographs obtained to accurately diagnose oral/dental disease and plan treatment. Oral/dental treatment always starts with professional dental cleaning. Image: David Černec

The gold standard at home is still mechanical plaque removal with a soft-bristled toothbrush (Roudebush et al, 2005; Ray and Eubanks, 2009; DeBowes, 2010; Figure 2). Tooth brushing results in an untargeted removal of bacteria from dental surfaces. In humans, brushing once per day was found sufficient to maintain oral health and prevent periodontal diseases, if performed appropriately. However, due to the fact most human patients have difficulty achieving an adequate tooth brushing technique, twice-daily brushing is recommended (Attin and Hornecker, 2005).

In animals, daily tooth brushing is recommended and should start when deciduous dentition is still present (Ray and Eubanks, 2009) and should be continued throughout the life of an animal (Resler, 2011; Ingham and Gorrel, 2001).

Method

An adequate technique applied for at least 30 to 60 seconds on each side of the mouth should be employed (Ray and Eubanks, 2009). Without opening the mouth of the animal and just lifting the lips, a tooth brush is placed at a 45° angle to the tooth and circulated over the dental surface – moving the bristles away from the gingiva and sulcus (Ray and Eubanks, 2009). It is best to start with easy-to-reach areas, such as the upper jaw, rostral teeth and buccal surfaces, and gradually teach the pet to tolerate brushing for extended periods of time, and more caudal teeth and lingual/palatal surfaces of the teeth (Resler, 2011). Tooth brushing is usually easier in dogs, hence, more data on the efficacy of daily tooth brushing are available for this species (Gorrel and Rawlings, 1996; Harvey et al, 2015; Watanabe et al, 2016) compared to cats (Ingham et al, 2002a).

It is very important to regularly remind and encourage clients to continue brushing their pets’ teeth daily as it has been shown only 53% of owners are compliant with oral hygiene recommendations six months after professional oral care (Miller and Harvey, 1994).

Tooth brushing may be complemented with a toothpaste, although products for human use must not be used due to their potential toxicity to animals (Resler, 2011). Toothpaste may improve an animal’s acceptance of tooth brushing (Resler, 2011); however, although particular toothpastes may reduce the number of oral bacteria in dogs, they are not as efficient at removing bacteria mechanically with a toothbrush (Watanabe et al, 2016).

Chews, rinses and sealants

In some animals, tooth brushing is very difficult or impossible, in which case, other oral home care measures need to be employed, although their efficacy will be less than that of tooth brushing (Ray and Eubanks, 2009). Depending on the chewing habits of the animal, chewing activity (Figure 3) is believed to enable the physiologic cleaning of teeth. Soft and home-prepared diets are associated with poorer oral/periodontal health (Watson, 1994; Harvey et al, 1996; Buckley et al, 2011). It has also been shown cats fed with kibble have different oral microbiome compared to those fed wet diets; however, the relationship with periodontal health remains unclear (Adler et al, 2016).

Figure 3. Chewing is associated with better physiologic teeth cleaning. Although (home-prepared) raw meat-based diets/treats may seem the most “natural” choice, scientific data is lacking on its effect on periodontal health in dogs and cats. Safety, nutritional adequacy, hygiene quality and other risks (including health risks to people) of feeding raw meat-based diets must be considered. Image: Tanja Plavec
Figure 3. Chewing is associated with better physiologic teeth cleaning. Although (home-prepared) raw meat-based diets/treats may seem the most “natural” choice, scientific data is lacking on its effect on periodontal health in dogs and cats. Safety, nutritional adequacy, hygiene quality and other risks (including health risks to people) of feeding raw meat-based diets must be considered. Image: Tanja Plavec

When selecting a diet, treat or toy to be chewed by the animal, it is important to consider the size and hardness of it to avoid dental fractures and intestinal blockage (DeBowes, 2010; Resler, 2011; BVDA, 2016). The toy or treat should be flexible enough so it can be bent and soft enough for it to be dented with the owner’s fingernail (DeBowes, 2010).

Several commercially available diets, chews and edible treats are proven to help with oral home care in pets by their mechanical or chemical action on plaque or calculus. In general, mechanical action of a diet/chew/treat is attributable to its textural characteristics (size, shape and consistency) that allows for maximal contact with the teeth (Roudebush et al, 2005). The chemical action of a diet, chew or treat comes from its added therapeutics – for example, chlorhexidine (Rawlings et al, 1998), or polyphosphates (usually added as coatings to help inhibit new dental calculus formation by binding salivary calcium, with limited success; Roudebush et al, 2005). Chews and edible treats are usually used daily, hence their amount should be limited and their calories counted towards the daily requirements of the animal.

Different dental chews are available where daily addition to a dry diet regimen has been proven to be effective in reducing plaque, calculus, oral malodour and gingival indices in dogs (Rawlings et al, 1997; Rawlings et al, 1998; Stookey, 2009; Quest, 2013), and also in cats (Ingham et al, 2002b). Daily addition of some chews has been shown to have an added oral health benefit when tooth brushing was performed every other day (Gorrel and Rawlings, 1996).

The efficacy of oral rinses, sprays, gels, water additives and wipes for teeth to reduce plaque and calculus accumulation is mostly attributable to the chemical action of the ingredients, which may vary.

The most commonly used chemical agent is still chlorhexidine. Chlorhexidine gluconate is the preferred form to be used in the oral cavity. It is a non-specific antimicrobial agent with a broad-antimicrobial spectrum and antiplaque activity; however, due to its specific mechanism of action, it does not promote bacterial resistance. Chlorhexidine exhibits substantivity and twice-daily application is recommended. In humans, if used long term, it may alter taste, stain teeth and increase calculus formation. It has a bitter taste that can significantly impact palatability in animals.

In animals it is usually used as a 0.12% solution, but dilution to 0.05% minimises the risk of tissue irritation. Chlorhexidine undergoes minimal metabolism (Davies and Hull, 1973; Resler, 2011; Balagopal and Arjunkumar, 2013). It is widely used perioperatively and in the immediate postoperative period, while data on its long-term use in animals are rare (Roudebush et al, 2005).

Zinc ascorbate used after professional dental cleaning has also been described in cats as an effective antiplaque agent that also reduces gingivitis (Clarke, 2001). Drinking water treated with xylitol at 0.005% each day was found to be effective in reducing plaque and calculus accumulation in cats (Clarke, 2006). Xylitol, however, should be used with caution – particularly in dogs, as it can cause liver failure (DuHadway et al, 2015).

Several other formulations or active ingredients (for example, cetylpyridinium chloride, enzyme systems, essential oils, herbal compounds and probiotics) are available and some regularly used by humans. However, it is prudent to check the safety of such ingredients for animal use, and scientific data supporting their efficacy in maintenance of periodontal health, prior to recommending such products to clients.

Dental sealants, applied immediately after professional dental cleaning, act as physical barriers for the accumulation of bacteria. They have been shown to be safe and to reduce plaque and calculus accumulation in dogs (Gengler et al, 2005; Sitzman, 2013) and cats (Bellows et al, 2012), but the effect on gingival indices varied or lacked in these studies.

Vets must strive to recommend a safe product to clients with a scientifically proven effect on the reduction of dental deposits (data ideally obtained from properly designed, randomised, controlled studies in target populations). When a commercially available product is considered, it is, therefore, best to ask the manufacturer for such evidence or visit the Veterinary Oral Health Council (VOHC) website (www.vohc.org) as a starting point. Products with the VOHC seal meet preset standards to retard plaque or calculus accumulation in dogs or cats (DeBowes, 2010).

Obtaining a VOHC seal is, however, voluntary and many products on the market do not have the seal, although this does not indicate they are ineffective. In addition, studies that test these products mostly evaluate the relatively short-term effect of the product, hence the data should not be extrapolated for longer periods. Moreover, key to optimal patient care is client education about the nature of periodontal diseases and hence the need for regular annual professional oral care complemented with daily oral home care (Ray and Eubanks, 2009).

When creating an optimal oral care plan, the animal, owner expectation and ability, the animal’s needs and cooperation, environmental factors and evidence supporting a specific therapeutic or preventive intervention should all be considered (Roudebush et al, 2005).