The ABCs of veterinary dentistry: "L" is for "Looks like we're too late"
Jan Bellows, DVM, DAVDC, DABVP, FAVD
Dr. Bellows asks whether we're not emphasizing prevention enough in the dental care of our patients.
Recently I was asked to give a talk titled, “How can a Chihuahua have full dentition into old age?” I stressed starting plaque control early once the permanent teeth erupt and performing periodic professional oral assessment, treatment and prevention (oral ATP) visits when gingival inflammation and halitosis were present, including extracting teeth affected by advanced periodontal disease.
On the way home from the talk it dawned on me that this approach to dentistry is in the wrong order. Our office sends yearly oral ATP reminders, but our clients are usually motivated to make an appointment to have their pet's teeth cleaned in response to oral malodor and not a card that arrives in the mail. Following our approach, we get into the mouth too late, practicing fire engine dentistry necessitating multiple extractions (Figure 1).
Figure 1. Advanced periodontal disease affecting the maxillary fourth premolar and first molar in a dog. (Photos courtesy of Dr. Jan Bellows)
Oral malodor originates from putrefying materia alba lying in periodontal pockets. This is the problem: Without proactive and very active plaque control, significant moderate to advanced periodontal disease arises in those dogs and cats that are prone. (Note: Not all dogs and cats automatically get periodontal disease because they have plaque and tartar. Periodontal disease is mostly an individual immune response resulting in inflammation and infection.)
Human dental patients are sent notices at least every six months for a prophylaxis, which is a procedure that involves cleaning the teeth ultrasonically and using hand instruments on a patient who does not have significant subgingival deposits or periodontal pocketing thanks to lifelong plaque prevention. The typical human prophylaxis patient has healthy gingival tissues, which do not bleed on gentle probing, and have no periodontal pockets over 4 mm in depth.
Human dentistry embraces prevention first. In our model of oral ATP, prevention is offered last. In the acronym that many veterinarians use-COHAT, or comprehensive oral assessment and treatment-prevention is not even mentioned. A small percentage of human patients need to have teeth extracted due to periodontal disease compared with the patients we work on, which generally have not benefited from dogged plaque control efforts.
Once you have embraced the concept of prevention first, share it with your clients. Consider replacing the terminology used in your practice from oral ATP or COHAT to COPAT-comprehensive oral prophylaxis, assessment and treatment-thus placing prevention first on the list and in your mind. When your clients understand the reasons behind frequent professional care-preventing pain and tooth loss-they are more apt to comply. It is for their pets' good and long-term welfare.
Prophylaxis and initial periodontal therapy: A quick review
Although periodontal disease cannot be completely reversed, dental prophylaxis is one of the tools we have to effectively decrease the progression rate of its destructive advancement. For most adult humans, prophylaxis is recommended twice annually as a preventive measure and every three to four months for periodontitis sufferers.
Here's the prophylaxis process in veterinary patients.
1. Supragingival cleaning: to thoroughly clean the area above the gum line with an ultrasonic scaler, removing most of the plaque and calculus (Figures 2A-2C).
Figures 2A-2C. An ultrasonic scaler used to remove plaque and calculus from a dog's maxillary fourth premolar.
2. Subgingival cleaning: for patients with early and moderate stages of periodontal disease to remove plaque and calculus from small gingival pockets beneath the gum line (Figures 3A-3C).
Figure 3A. A curette before subgingival insertion.
Figure 3B. Extension of the curette subgingivally.
Figure 3C. Removal of subgingival debris.
3. Tooth-by-tooth examination with full-mouth intraoral radiographs: to show the extent of bone support loss.
4. Root planing: smoothing of the accessible tooth root with a curette by the veterinarian to eliminate remaining calculus and plaque.
5. Medication: following scaling and root planing, antimicrobial medication can be placed into bleeding sulci or moderate periodontal pockets (Figures 4A-4C).
Figure 4A. Bleeding on probing and a 5-mm periodontal pocket along the mesial root of the left mandibular first molar.
Figure 4B. Application of a local antimicrobial (Clindoral-TriLogic Pharma) into the cleaned pocket.
Figure 4C. A local antimicrobial bleb after application.
What to do now?
Here are the action steps to put prevention first to preserve your patients' teeth now rather than on the treatment table:
1. Start early with each puppy and kitten. Twice-daily efforts to decrease the accumulation of plaque are vital to keep teeth and gingiva healthy. Communication is the cornerstone to make this happen lifelong. The exchange of information and the connection to patients will result in understanding the value of why they need to practice this lifelong habit.
2. Show clients how to use wipes on the outside of a dog's deciduous teeth first and permanent teeth when they erupt (Figure 5). Watch clients perform a wiping. In cats, rubbing a long cotton-tipped applicator dipped in tuna juice on the buccal and labial surfaces of the gingival margin will help control the daily accumulation of plaque.
Figure 5. Using wipes to remove daily plaque accumulation.3. Once a dog is 6 months old, tell clients to feed a Veterinary Oral Health Council (VOHC)-accepted daily chew.
4. Encourage the use of as many VOHC-accepted products as possible.
5. Perform the first COPAT at 1 year of age and repeat when there is inflammation at the gingival margin (vs. the calendar reminders).
7. After the COPAT visit, encourage monthly dental progress visits to complement your client's efforts at plaque control and make improvement suggestions if needed.
Hurdles to overcome
What has stopped us from practicing prevention-first companion animal dentistry? Three obstacles: 1) anesthesia for the prophylaxis, 2) money and 3) perceived difficulty of performing home care. How can we diminish these concerns and place prevention first?
The delivery of safe anesthesia has come a long way over the past years. Thanks to routine preanesthetic testing, we now know more about our patients, we can tailor the use of specific preanesthetic and anesthetic medications for each patient, and we monitor vital parameters throughout and after the prophylaxis. Adverse anesthetic events are rare. A scientific study of 98,000 average 8-year-old dogs anesthetized for at least one hour by general practitioners and specialists showed that the death rate under anesthesia is 0.15%.1 This means 99.85% of patients survive anesthesia and sedation.
Spending $300 plus on the preoperative testing, intravenous fluids, anesthesia and COPAT may seem excessive when clients compare their pets' teeth cleaning with their own. Here is when discussion of the value of what we do before, during and after the prophylaxis pays off.
Fortunately with the advent of wellness plans, the prophylaxis in many hospitals is rolled into monthly or yearly premiums similar to human dental insurance. For those patients not on a wellness plan there are many payment plan alternatives, which help alleviate the money issue.
> Perceived difficulty and ineffectiveness of home care
The patient's immune response to plaque accumulation is the proximate cause of periodontal disease-more plaque and more rough tartar supports more plaque to irritate and infect underlying gingiva in those susceptible patients. The key to preserving teeth into old age lies in implementing a twice-daily plaque prevention program understood and supported by your clients and everyone in the office.
What you choose for home care is key. Tooth brushing, the gold standard, is not practiced enough because most clients are not willing (or able) to put their fingers inside their pets' mouths. Sending your clients to the pet store for nonefficacious homecare products is a waste of their time and money and is potentially dangerous for dogs chewing on bones, antlers, hard nylon toys and bully sticks.
The VOHC accepts products (diets, chews, toothpaste, water additives and even a toothbrush) that have been shown to decrease the accumulation of plaque and/or tartar by at least 15% and an average of 20% in two studies. (Here's a quick guide to the dental chews.) Currently there are 36 dog and 12 cat products accepted.
Each prevention program needs to be tailored to the specific pet. What I have found most acceptable and effective is using dental wipes in the morning to rub away accumulated plaque and prescribing a VOHC-accepted dental diet followed by feeding a VOHC-accepted age- and size-appropriate dental chew in the evening after dinner. Aggressively promoting prevention first will make the largest impact in stopping periodontal disease and tooth loss. Your patients' (and clients') smiles will be easier to see with teeth.
1. Brodbelt D. Perioperative mortality in small animal anaesthesia. Vet J 2009;182(2):152-161.
• Brodbelt DC, Pfeiffer DU, Young LE, et al. Results of the confidential enquiry into perioperative small animal fatalities regarding risk factors for anesthetic-related death in dogs. J Am Vet Med Assoc 2008;233(7):1096-1104.
• Brodbelt DC, Hammond R, Tuminaro D, et al. Risk factors for anaesthetic-related death in referred dogs. Vet Rec 2006;158(16):563-564.