Improving veterinary dentistry: Partner with pet owners for better oral care (Sponsored by Greenies)

With advances in dental procedures and home care products, the veterinary dental care offered today is better than ever. Yet, there is always room for improvement, and some pets are not receiving the care they need and deserve. Recently, a group of veterinary dental experts got together to discuss gold standards in veterinary oral care and how practitioners could deploy this care in their hospitals and engage clients to practice oral care at home.

Today's veterinary dental care

Dr. Karyl Hurley (moderator): Let's start off our discussion with how you would summarize the state of veterinary dental care and what breakthroughs have been made in this area.

Dr. Brook Niemiec: There is a shift in our approach to treating periodontal disease. What we have done in the past was focus on controlling the pathogen—plaque control. Now we are not only doing that, but we are also focusing on decreasing inflammation through the use of products such as fatty acids and statins. We also have bone regeneration agents.

Brook Niemiec, DVM, DAVDC, FAVD Owner of Southern California Veterinary Dental Specialties in San Diego, Calif., and president of the Academy of Veterinary Dentistry

Dr. James Anthony: For the new veterinary dentist or practitioner, the biggest breakthrough may be diagnostic dental radiography. Certain radiography systems available today have made diagnosis a lot easier. With electronic media, practitioners can email radiographs to any boarded veterinary dentist. As a result, animals are treated more effectively and more appropriately.

Dr. Jan Bellows: In our practice, the commercially available oral test strip has made a giant difference. It starts white, and if there is significant periodontal disease, it turns yellow. The degree of color change seems to correlate with the degree of periodontal disease. Every patient in for a wellness examination or vaccine examination gets one. Clients see that what they thought was doggie breath is periodontal disease, and they are coming in to have their animal's teeth cleaned under anesthesia a lot quicker.

Dr. Niemiec: We see an emerging trend of specialists doing highly advanced procedures—implants, periodontal surgery, and root canals, for example. In many ways, some animals get better dental care than many people do. However, dental specialists care for a small percent- age of the pet population. Only perhaps 3% to 5% of general practices are doing a really good job. There are still many general practices that are not providing adequate dental care to their patients.

Dr. Bellows: Veterinarians are trying to do a better job in this area. There are more veterinarians purchasing dental radiography machines, and wet labs are filled up. Clinicians recognize that dentistry is an important part of an animal's well-being, and they want to improve the dental care they offer.

Jan Bellows, DVM, DAVDC, DABVP, FAVD Owner of All Pets Dental in Weston, Fla., and president-elect of the American Veterinary Dental College

Dr. Anthony: Unfortunately, many of the veterinary schools are lacking in teaching dental education. Most practitioners have to seek outside educational experiences just to raise their skills in dentistry to a minimum level of competency. Practitioners have the desire to do a good job, but they do not have the necessary skills or background to do it properly.

Ms. Debbie Boone: In multidoctor practices, there is often only one doctor who is excited about dentistry. That is the one who seeks further education, goes to wet labs, and actually trains the technical team. Within a practice, there can be a huge range in skill level.

Ms. Mary Berg: We also see a lack of dental education within technician programs, yet one of our main jobs as veterinary technicians is the dental cleaning procedure. A lot of practices use the dental arena as a major profit center, which leads to a do-as-many-in-aday- as-possible mentality. Patients may or may not get any benefit from this quick-and-dirty approach. In some clinics, technicians perform 10 cleanings a day. There is no way to do a good job at that pace. Taking your time and doing it correctly is the only way.

Consequences of periodontal disease

Dr. Hurley: When pets do not get the oral care they need, what are some of the consequences?

Dr. Niemiec: There are both local and systemic effects of periodontal disease. Local effects are broken jaws, eye loss, nasal infections, and abscessed teeth. It has come out recently that there is an increased risk of oral cancer in people with bad periodontal disease. Yet, that is nothing compared with the systemic effects of periodontal disease. A direct cause-and-effect relationship has not been described, but there are many studies that strongly correlate bad periodontal health or dental disease with systemic effects. There are 181 references for my new periodontology book's chapter on the systemic effects of periodontal disease. The references are mostly human studies, but there are numerous ones in pets as well, and I am missing some of the ones that just came out. We are seeing new information on the systemic effects of periodontal disease every single day, and they involve the heart, lungs, liver, kidneys, and brain. There are several mortality studies showing that people with bad periodontal health die earlier than people with good periodontal health do, and there are studies showing that treating the mouth will actually improve the parameters of the glomerular filtration rate, liver function, and insulin control. For years we have said, "Your dog has a heart murmur. He can't have a cleaning." "Your dog has diabetes. He can't have a cleaning." "Your dog is 7. He is too old for a cleaning." We need to make a shift to saying, "Your dog has a heart murmur. He needs a cleaning." "Your dog has kidney disease. He needs a cleaning."

Dr. Bellows: Thank goodness for anesthesia monitors and the new anesthetic and pain protocols. Dental care under anesthesia is really safe, and it is rare that something adverse happens.

Engaging clients

Dr. Hurley: How do you educate clients about dental disease and oral health care?

Ms. Berg: When I'm talking to clients, I compare it with what we as humans have going on in our mouths. Most people have had periodontal disease themselves or know someone who has had it. They realize that periodontal disease is something that can affect internal organs down the road.

Debbie Boone, BS, CCS, CVPM Owner of 2 Manage Vets Consulting in Gibsonville, N.C.

Ms. Boone: Looking into a pet's mouth is often not a part of a client's routine, and some veterinarians fail to mention dental disease to owners. The entire veterinary team needs to be focused on the importance of oral care.

Dr. Niemiec: One thing that we need to convey to clients is that treating periodontal disease is not cheap. I hand them GREENIES® dental chews and a toothbrush and say, "Use these if you want avoid having to come to me so often." We all need to work on how we engage clients.

Dr. Hurley: What tools are available to get the importance of home care across?

Dr. Niemiec: On my website (www.dogbeachdentistry.com), I have videos in which I describe periodontal disease and therapy, drawing out the causes and progression of gum disease—the eye problems, nasal problems, and jaw fractures. Then I say, "This is how you treat periodontal disease: home care, professional cleaning, periodontal surgery, extraction." The video includes pictures of oronasal fistulas, pathologic fractures, and eye loss. I also show how to regenerate bone and other therapies.

Ms. Boone: Clients retain about 20% of what we tell them. Giving them handouts raises their level of comprehension to about 75%. I use Webster Veterinary's DIA product in a lot of practices. It shows the progression of dental disease, and you can email the information to clients. There are educational tools available if you take advantage of the technology.

Dr. Bellows: I take a picture in the examination room by using an inexpensive digital camera with an Eye-Fi card. It uploads the photo to the computer screen instantly, and then we print out the photo for clients. I use the photos to show clients exactly where the problems are. We have literature as well, and there are a lot of good brochures available that show the disease progression.

Dr. Anthony: Having something tangible brings the story home. If you give clients a pamphlet with a picture, circling an area and saying, "This is what is going on with your pet," it has a dramatic impact. Clients are more likely to realize how much harm and discomfort periodontal disease will cause to their pet.

James Anthony, BSc (Agr.), DVM, MRCVS, DAVDC, DEVDC, FAVD, PAg President, Pacific Dental Service for Animals Ltd.; veterinary dentist at Central Animal Hospital in Saskatoon, Saskatchewan, and at Red Bank Veterinary Hospital in Red Bank, N.J.; and VOHC member

Dr. Hurley: How do you emphasize the importance of preventive care to clients?

Ms. Berg: We put oral health information in the puppy kit, but we often wait until a puppy's second or third vaccine appointment before we really hit hard on the dental information because it can be overwhelming. We want to make sure that clients are focused on what we are talking about.

Dr. Bellows: At the fourth puppy visit, we give clients dental wipes infused with sodium hexametaphosphate at no charge and show them how to use them. Even though the dogs still have their deciduous teeth, using the wipes gets the puppies and owners used to the whole experience. We used to give clients a toothbrush and toothpaste, but we found that they did not follow up with that. Some pets we do not see as puppies. They show up as adults for a dental procedure. After they get a professional cleaning, we send them home with dental wipes and other products as well. We recommend Veterinary Oral Health Council-accepted products.

Oral health home care

Dr. Hurley: Let's address home care products specifically. What do you recommend, and what does the VOHC seal mean to you?

Dr. Bellows: VOHC stands for the Veterinary Oral Health Council, which was established 15 years ago as an independent board of veterinary dentists who evaluate studies on the efficacy of dental products to see how they retard the progression or growth of plaque or tartar. To receive a VOHC seal of acceptance, products have to produce at least a 20% decrease in the growth or progression of plaque and/or tartar. Products that have a VOHC acceptance seal stand apart from products that do not have the seal. Products that do not have the acceptance seal may work, but they have not been evaluated by an independent board. It is similar to the American Dental Association (ADA) seal on the side of toothpaste containers. We also recommend feeding diets that decrease plaque and tartar. Many of our clients feed GREENIES® Canine dental chews every day or twice a day. We also recommend a rawhide chew product that has chlorhexidine in it, which is good for dogs that aren't gulpers. We also recommend dental wipes, especially the ones that have sodium hexametaphosphate in them. Additionally we use a plaque prevention gel that is applied both professionally and with the owner's fingers or an applicator weekly thereafter. The gel is applied to the area where the gingiva meets the tooth on the buccal surfaces. Daily plaque accumulates on the waxy gel rather than underneath the gum line. We also use a VOHC-accepted veterinary dental sealant. We use it on almost all patients because there are places that owners are not going to reach with brushing. To help reduce plaque in cats, we use a cotton swab dipped in tuna juice to brush their teeth. I tell clients that tuna juice has absolutely nothing to do with controlling plaque, but cats like the taste. They do not like the taste of the wipes. I find that the cotton swabs get right at the right place. There are also dental preventive treats. We suggest FELINE GREENIES® Dental Treats, which are the only VOHC-accepted treats for cats to help to control tartar.

Dr. Niemiec: There are a lot VOHC-accepted options available. Home care is customized for each client. Most clients are not going to brush their pet's teeth regularly, so you have to give them other options. I have asked every company with a dental product, "Can I see your research?" Two-thirds of them said, "We don't have any research, but look at these beautiful pictures." But some of the products that have VOHC approval—GREENIES® dental chews and treats being among them—said, "Here is our research." I recommend VOHC accepted products, but I also tell veterinarians to look at the primary research if they can.

Dr. Bellows: It is a matter of choosing the best approach tailored to each patient and client. The manufacturer's instructions caution against using the gel and the sealant together or the sealant and fluoride together. So you must decide. It is customized based on the client, and it is sometimes predicated by expense or by the animal's willingness to accept home care.

Dr. Anthony: There are more than 2,000 oral home care products in the veterinary market today. Do I know all of them? The answer is absolutely not. We try to customize a plan to meet the owner's and the patient's needs. Two weeks after an oral hygiene procedure, we have the owner and patient come back, and we talk about home care and show them how to do it. In two weeks, the animal has healed. It's healthy, and it's pain free. As a result, right then is the best opportunity for success with home care. First we recommend brushing, and we show the owners how to do it. We say it should only take 30 to 60 seconds. The second thing we do is dispense a chlorhexidine-based oral hygiene rinse because its antibacterial, antiviral, and antifungal activities help control plaque buildup. We will also dispense an ascorbate acid-based product to promote collagen formation in the gums. Then we dispense esterified fatty acid complex. We apply it topically to the inflamed areas. It helps decrease the production of inflammatory byproducts such as interleukin-7, interleukin-3, tissue necrosis factor, and prostaglandin release. As a result, the inflammation is almost eliminated. Then we talk about dental diets. GREENIES® Canine Dental Chews are the top of the line. If a client cannot do any of the previous things, then we start adding other options like water additives. There are effective water additives out there. The only downfall I have seen with them is that if the animal has an astute palate it will not drink the water and can dehydrate if the owners are not careful.

Dr. Niemiec: I use water additives, but honestly, it is for clients who are not going to feed GREENIES® Canine Dental Chews or brush the teeth or use a wipe. If the clients say they are not going to do anything, then I'll tell them to try a water additive.

Oral hygiene procedures

Dr. Hurley: When do you recommend an animal have its first cleaning? Do you recommend all pets come in every six months?

Ms. Berg: We assess the individual patient to determine when is best for it to have a dental cleaning, and then my goal is for the owners to learn proper home care so that they can stretch the interval out to 18 months or longer. I want them to do what they can at home to prolong the time in between dental cleanings and understand what changes to look for to determine when I see them again.

Dr. Anthony: I recommend that veterinarians perform a full wellness examination, including an oral examination, every six months. Ideally, home care addresses problems early enough to prevent a future problem that requires a general anesthetic to get the teeth cleaned. If owners are providing good oral home care, the need for an oral hygiene procedure can be delayed for many years.

Dr. Bellows: We start with a professional oral care visit at 6 months of age. We emphasize prevention at that visit and send patients home with dental care products. Dental health recommendations are then tai- lored to the individual patient after that, based on how well the home care is performed.

Dr. Niemiec: I tell clients that brushing teeth is like changing the oil in your car. Yes, it is a pain to go and get it done. But if you do not change the oil in your car, then you may have to change your engine every three or four years. If you change your car's oil regularly, your engine is going to last, and if you brush your pet's teeth, then the teeth are going to last.

Ms. Boone: One of clients' big fears is anesthesia. When teaching them preventive care, we can say, "We won't have to put Cooper under anesthesia quite as often if you do these things at home. Yes, we need to get the teeth good and clean, but after that, let's prolong the time to another cleaning as long as we can."

When the cost is a concern

Dr. Hurley: What happens when you have clients with multiple dogs or cats who cannot afford to bring all of their pets in for twice yearly oral hygiene procedures or even rechecks?

Ms. Berg: We recommend that they feed their pets a quality dental diet if they can. And there are other things that can be done at home, such as giving GREENIES® Canine Dental Chews.

Dr. Bellows: Pet insurance really helps make things affordable. We also try to get clients on a regular professional oral assessment, treatment, and prevention visit schedule, so disease does not progress until multiple extractions remain the only viable care. We explain to owners that home dental preventive care allows time with their pet—their companion. They can turn it into something positive, whether it is throwing a dental chew up in the air and letting their pet chew it or using a wipe or a toothbrush twice a day.

Dr. Anthony: Oral home care does not take more than two minutes a day per pet. Some people think that you have to brush for 10 minutes. It only takes 30 to 60 seconds to brush a pet's teeth properly, and the cost of home care products ranges anywhere from $1 to maybe $3 per day. There are many products that can be used to customize dental care. It is not just a matter of having to brush every animal's mouth.

Mary Berg, BS, RLATG, RVT, VTS (Dentistry) Practice manager and dental specialist at Gentle Care Animal Hospital in Lawrence, Kan., president of MLB Consulting, and president-elect of the Kansas Veterinary TechniciansAssociation

Dr. Niemiec: Brushing options are dirt cheap. The diets and treats are a little bit more expensive. The fact is that it is more than just dental home care. GREENIES® Canine Dental Chews are nutrition, food, and positive reinforcement. From a financial standpoint, performing home care will save, save, save. Without home care, pets need annual cleanings.

Dr. Hurley: How do you approach clients with an estimate or handle additional costs?

Ms. Berg: When I'm putting together a treatment plan, I always go one degree higher than I think it is going to be. I talk to clients and say, "Charlie's teeth are in bad shape right now, but we are going to fix the problem. My goal is that next time the cost can be much lower because we have taken care of a lot of the problem, especially if you are doing your part at home." Owners are usually fine as long as we explain the costs in detail. It is when a bill has suddenly tripled and nobody has talked to them that they get upset. Honestly, I don't blame them.

Karyl Hurley, DVM, DACVIM, DECVIM-CA Director, Global Scientific Affairs, Mars Petcare

Ms. Boone: You are right, Mary. "By the way, we had to remove three teeth that we did not tell you about, and that is going to be an extra $200." Clients are not particularly happy about that. People do not like to be blindsided. It costs the client less to be proactive, to clean the teeth at an earlier stage when it not only costs less but is better for the animal.

Dr. Anthony: If you have taken pictures before and after the procedure and if you print them off for the clients to see, then they realize the extent of the problem and the extent of what you did. Then they have a perceived value.

A team effort

Dr. Hurley: Veterinarians cannot do all of the client education and communication on their own. You need support. What kind of a team do you need?

Ms. Boone: We start with whoever answers the telephone. You should have the reception team educated enough to give a good answer when asked, "How much does it cost to clean my dog's teeth?" If it becomes more complicated, then they will pass it over to the technical team member. Then sometimes we have to get the white coat to help them make a decision or to answer more complex questions. It is a total team effort from beginning to end, back out to the reception team member who is ringing up the charges and looks at that client and says, "You did such a great thing for your animal. Good job." What gets praised gets repeated. It is important that every team member praises clients for doing what they should be doing and reinforcing their decision to walk in that door.

Ms. Berg: Your entire staff must be on board with what you are doing when it comes to dentistry.

Dr. Bellows: It is like a symphony in the office because everybody is involved, from getting the animal checked in, anesthetized, imaged, and probed; the disease diagnosed; the owner called; the animal treated, awakened, and bathed. Team members in the front of the office are getting the booklet together that summarizes the diagnosis and treatment and has all the blood work results, radiography reports, and pictures. They save the booklet as a PDF file and put it in my Dropbox folder, so I can go into the exam room with my iPad and review it with the client.

Dr. Anthony: It is important to have a team approach for home care as well. It has got to be a unified approach, and everybody has to be on board with it.

Ms. Boone: It is similar to the approach for flea and tick control, vaccinations, and nutrition: Provide a consistent message.

Dr. Bellows: We customize the home care for each pet. During the examination, I circle items on a product list that I think the patient needs, and those products are waiting up front when the owner checks out. My receptionist knows when she is speaking to the client on the way out which things I circled. She is cognizant of how to use all of the products. It is bad for clients to spend their money and then see a receptionist who does not know how often you are supposed to give a GREENIES® treat (once or twice daily) or how to use the wipe or which part of the teeth to brush (the outside surfaces of all teeth that can be accessed) or whether you brush the tongue (no).

The role of social media

Dr. Hurley: How much do you use social media to communicate with clients?

Ms. Berg: Our clinic is fairly new to Facebook. We do not have a tremendous amount of clients following us yet, but we are getting more all the time. We try to post pertinent information.

Ms. Boone: Now you have to be on Pinterest, too, where you can pin something from the Web to your site. I pin things like the GREENIES® brand website or some of Dr. Niemiec's information.

Dr. Niemiec: Our videos are on Twitter and on our Facebook page.

Dr. Bellows: Our Facebook page has a fair amount of followers. We put interesting cases on our page, making sure they are not too graphic.

Ms. Berg: We try to direct clients to the more credible sites rather than having them do a GOOGLE search.

Dr. Anthony: I am not technologically advanced, but I realize the need for these things as an area of marketing potential. A lot of practitioners out there are in the same shoes as I am.

Ms. Boone: I read some research from Forrester Research that said between now and 2014 there will be a 62% increase in online sales. We cannot afford to ignore an increase in online purchasing of that size. It is vital that practices have an online presence, so owners can safely buy products that are unadulterated. The main thing you need to remember about social media is to put things there that are helpful to clients. Information on behavior is something that is always helpful to clients and keeps them coming back.

Dr. Bellows: In human dentistry, buying GOOGLE keywords is another opportunity. For example, if you happen to be an orthodontist, you might buy the word orthodontics. Dentists are only paying for the people in their area—so nobody in Chicago sees the ad if you are in Miami. In human dentistry, it is rampant, and dentists love it. In the future, veterinarians will be using GOOGLE ADWORDS.

What is GOOGLE ADWORDS?

Ms. Boone: You can do that on Facebook, too. There are a lot of things that veterinarians can do to keep in front of clients. We need to be taking advantage of these things.

Final thoughts

Dr. Hurley: Are there any misconceptions about dental care that you would like to dispel?

Ms. Boone: According to a 2011 ASDA Pet Insurance Company survey, 81% of people consider their pets "very important" to their family. We need to present our care that way. Unfortunately, many veterinarians have the mindset that people will not pay for advanced veterinary care. Last year in the United States, millions of dollars were spent on clothing for animals. Animals do not need clothes to be healthy. They need dental care. We need to be aware that people will pay to take care of their family members.

Dr. Bellows: And they want them to have greatsmelling breath.

Ms. Boone: Yes, because they want to kiss them!

Dr. Hurley: I want to thank all of you for participating in this discussion. We have covered a lot of what oral health care is, can be, and should be in veterinary practice today. It seems that there are many ways to educate clients and individualize oral health care through a combination of oral hygiene procedures and home care. Without the cooperation and partnership of specialists such as you, we could not make the progress that we have in the field of veterinary dentistry, helping to raise the level of discussion that veterinarians have around oral care. Ultimately, what we are here to do is to make the world a better place for pets. So I just want to say thank you again.

Passionate about veterinary dentistry?

If you are passionate about dentistry, there are many ways to expand your skill set and network with other like-minded practitioners.

• Study to become a diplomate of the American Veterinary Dental College (avdc.org).
• Join the Academy of Veterinary Dentistry (avdonline.org).
• Study to become a fellow of the Academy of Veterinary Dentistry (avdonline.org).
• Get hands-on training at a dental wet lab at a veterinary conference (avdc-dms.org/dms/list/events.cfm?wl=1; San Diego Veterinary Dental Training Center at vetdentaltraining.com).
• Become a member of the American Veterinary Dental Society (avds-online.org).
• Test your oral health knowledge with continuing education quizzes (oralatp.com).
• Get feedback from dental experts by posting a case on the Veterinary Information Nerwork Dental Center (vin.com).

Online resources for pet owners

Owners often search online for pet health information. Make sure they are getting good information by providing links to these websites on your hospital's website or Facebook page or by pinning them through Pinterest.

• www.dogbeachvet.com: Dr. Brook Niemiec's website features videos about dental care.

• www.dentalvet.com and www.allpetsdental.com: Dr. Jan Bellow's websites are full of photos and articles about preventing periodontal disease, including a step-by-step guide to brushing a dog's teeth.

• www.greenies.com: The library contains valuable resources on dog and cat dental health and many other pet health topics.

• www.vohc.org: The Veterinary Oral Health Council website explains in layman's terms what periodontal disease is. There is also a list of VOHC-accepted products.