Periodontal disease is the most diagnosed condition in canines within the UK (O’Neill et al, 2021) and is described as plaque-induced disease of the periodontium. Its early stage, gingivitis, is characterised by inflammation of the gingiva, caused by plaque bacteria, and is reversible through dental prophylaxis and homecare (Niemiec, 2008). Periodontitis, the later stage, occurs when the deeper structures, the periodontal ligament and alveolar bone, are affected, and unlike gingivitis, the damage is irreversible (Niemiec, 2008).
According to the Code of Conduct for Veterinary Nurses, animal health and welfare is the priority for veterinary professionals (Royal College of Veterinary Surgeons, 2022). It is crucial, therefore, that professionals work together with animal owners to reduce occurrences of periodontal disease clinical signs and complications such as tooth loss, tooth mobility, dental abscess, halitosis, oral-nasal fistulas, blindness, oral cancer, osteomyelitis and pathogenic mandibular fracture (Niemiec, 2008; McFadden and Marretta, 2013). These conditions can cause pain, negatively impacting quality of life, and can lead to the need for invasive veterinary treatment under general anaesthesia (Niemiec et al, 2020).
Early prevention of periodontal disease is important for the continued welfare of the animal, and effective dental homecare can prevent and reverse gingivitis (Niemiec, 2008). Good oral health is achieved through effective homecare, alongside periodic veterinary checks, and treatment (Wallis and Holcombe, 2020). The primary goal of dental homecare is to prevent the development of gingivitis and periodontal disease through daily plaque control (Roude-bush et al, 2005). Active methods of homecare such as toothbrushing are recommended, alongside passive methods like dental chews (Niemiec et al, 2020) and solutions such as PlaqueOff (Gorrel et al, 2013; Harvey et al, 2015; van Dijken et al, 2015; Gawor et al, 2018; Niemiec et al, 2020) (Table 1). In regards to owner compliance, passive methods are normally more achievable within a busy daily routine, however, evidence suggests that dogs with healthy teeth need active methods to be carried out a minimum of three times per week, while those animals with signs of decay need this increasing to daily to be valuable (Buckley et al, 2011). Veterinary teams must also be aware of the disadvantages of some passive methods, such as bones, which can cause damage to teeth when biting compared with manufactured dental chews (Clarke et al, 2011; Pinto et al, 2020) (Table 1).
Table 1. Methods of dental homecare for preventing development of gingivitis and periodontal disease
| Method | Advantages | Disadvantages | |
|---|---|---|---|
| Active | Toothbrushing | Most effective for controlling plaque accumulation and preventing periodontal disease | Efficacy depends on owner compliance and technique |
| Textiles | Beneficial while training for brushing | Unable to clean below the gum line | |
| Ultrasonic toothbrush | Anecdotal evidence in human dentistry suggests they aid reduction of plaque and calculus | No reliable published research to support their use | |
| Dog toothpaste | Palatability helps acceptance of toothbrushing | May contain abrasive particles that gradually wear on tooth enamel | |
| Passive | Chew toys and bones | May reduce plaque and dental calculus | Risk of dental damage, fractures, pathogenic exposures and zoonotic diseases |
| Dental diets | Aid control of plaque and calculus | No evidence they improve established periodontal disease | |
| Special dental chews | Limit plaque and calculus formation Increased palatability equals increased owner compliance | Efficacy may be affected by breed and size. Risk of oesophageal obstruction, gastrointestinal upset and weigh gain | |
| Chlorhexidine | Reduces plaque and gingivitis, particularly in established periodontal disease and post professional clean | May cause yellow staining of teeth and unpalatable taste reduces animal compliance | |
| Ascophyllum nodosum (PlaqueOff) | Improves oral health. Passive method means increased compliance | Rare occurrence of gastrointestinal upset |
Evidence consistently suggests that owner compliance is a limiting factor to the performance of adequate toothbrushing (Harvey et al, 2015; Allan et al, 2019) and research completed in Sweden concluded that less than 3.7% (n=2218) of canine owners performed daily toothbrushing (Enlund et al, 2020a). Similarly, a Royal Canin poll revealed that only 7% (n=39) of Canadian dog owners brushed their dogs’ teeth daily (Simpson, 2008). This is supported by previous research that showed compliance rates not exceeding 53% at 6 months or more after an owner received a toothbrushing recommendation. Many owners (45%; n=23) also failed to recall how they received the recommendation to begin with (Miller and Harvey, 1994).
Owner compliance issues have been suggested to occur from a lack of knowledge regarding canine dental health (Enlund et al, 2020a, 2020b; Niemiec et al, 2020). Further education from veterinary professionals may be required to support and increase compliance with effective dental homecare and, as a result, animal welfare (Wallis and Holcombe, 2020). Time constraints have been suggested as the barrier to veterinary surgeons providing in-depth discussions with owners regarding preventative healthcare (Belshaw et al, 2018). However, the provision of veterinary nurse-led clinics can help to alleviate pressures on veterinary surgeons by reallocating the workload and allowing time for owner education (Wild, 2017).
Research was conducted to gain insight into UK owners’ awareness of canine dental issues and the influence of veterinary professionals on this, to establish whether further education of owners by veterinary professionals would make a difference to the outcome for dogs.
Method
A low-risk ethical code was obtained from the Hartpury Ethics Committee before commencing the project: ETH-ICS2020-22-LR.
To allow both quantitative and qualitative data to be collected a questionnaire was designed on Microsoft Forms (Office 365), consisting of 31 questions, and adapted from a previously validated study (Enlund et al, 2020a). The questionnaire was published online for 1 month in 2020. It was shared via the Hartpury University email network and conveniently available social media groups, such as ‘vet nurse chatter’, ‘all things dog UK’ and ‘Bristol dog community’, and was focused on dog owners in the UK. Categorical data and Likert scales were used to collect nominal and ordinal data for analysis. Demographic data were descriptively analysed using frequencies, mode and medians (Walliman, 2018) and IBM Statistical Product and Service Solutions (SPSS) version 26 was used to analyse inferential data. The ordinal data were assumed to be non-parametric (Nahm, 2016), so the Kruskal-Wallis test for difference was run, followed by the Bonferroni post-hoc test (Pallant, 2020). Qualitative data were analysed using thematic analysis (Braun and Clarke, 2006).
Results
A total of 422 participants completed the questionnaire and the results revealed that only 4% (n=16) of owners used a toothbrush daily while 50.9% (n=204) had never performed toothbrushing and 92% (n=369) had never used dog toothpaste. Results also revealed that 53.1% (n=213) of respondents said they had never been recommended to brush/clean their dog’s teeth by a veterinary practice. Of those who had received a recommendation, 47.4% (n=82) stated it came from the veterinary surgeon, 22.5% (n=39) had received the recommendation from a veterinary nurse, and 24.9% (n=43) said it came from both surgeon and nurse, and 5.2% (n=9) said they were unsure.
Of respondents, 25.7% (n=103) stated that inspecting or looking at all their dogs’ teeth was ‘very difficult’ or ‘fairly difficult’, while 74.3% (n=299) stated it was ‘very easy’ or ‘fairly easy’. Canine behavioural reasons were listed as the main cause for any difficulties experienced. Owners were asked what they considered to be important for good dental health in dogs. Special dental dog food and dental chews were selected to be of minor importance by 39.7% (n=149) and 36.7% (n=147) respectively, with 33.7% (n=135) rating toothbrushing as very important.
Qualitative analysis revealed themes that indicated many owners experienced difficulties in inspecting dogs’ teeth, were non-compliant with recommendations, or had a lack of knowledge and awareness of canine dental homecare. Reasons for the lack of performance of daily toothbrushing included the lack of awareness of its importance, their own abilities, and time constraints, alongside the dog’s behaviour and acceptance of toothbrushing (Table 2).
Table 2. Themes and quotes from qualitative analysis
| Theme | Quote |
|---|---|
| Diet | ‘He is fed a raw diet with plenty of bone which keeps his teeth and breath fresh and clean’ (Respondent 8) ‘He is on dry food, which seems to help keep it at bay’ (Respondent 213) |
| Behaviour | ‘My dog gets stressed when I clean his teeth, so I do it less frequently than it should be done, but when I do it I ensure they are given a good clean’ (Respondent 197) ‘Too hyper to cooperate’ (Respondent 284) |
| Other products | ‘Use a gel on his gums and plaque stuff in his food’ (Respondent 59) ‘…I don’t feel the need to use artificial products…’ (Respondent 79) |
| Lack of awareness | ‘I didn’t know brushing your dog’s teeth daily was a requirement.’ (Respondent 340) ‘It has not been recommended for us to do so by the vet’ (Respondent 427) ‘The importance of this hasn’t been stressed to us, and not sure how I would be able to’ (Respondent 183) |
| Time | ‘I try to brush her teeth daily but usually forget and do every few days’ (Respondent 358) ‘Laziness/lack of time’ (Respondent 305) |
| Difficulty to perform | ‘I didn’t pursue brushing as it was quite difficult’ (Respondent 126) |
Results from the inferential analysis revealed there was a significant difference between the frequency of homecare being performed by owners and whether they had received a recommendation from a veterinary practice, except in the case of dental textiles (P=0.439). There was a statistically significant difference between recommendations from veterinary practices and the frequency with which owners were performing toothbrushing (P <0.001).
Discussion
A low proportion of owners were found to be brushing their dogs’ teeth daily, in accordance with existing evidence (Simpson, 2008; Harvey et al, 2015; Enlund et al, 2020a). Allan et al (2019) stated that the best method for preventing periodontal disease at home is toothbrushing. Therefore, there is still a need for veterinary professionals to communicate these findings to owners to prevent dogs in the UK receiving insufficient dental homecare. It may be beneficial to disseminate these findings to both veterinary professionals and owners, in order to decrease the cases of periodontal disease in dogs.
Over a quarter of respondents claimed to experience difficulties when inspecting their dog’s teeth, which mirrored results found by Enlund et al (2020b). While many owners can inspect their dog’s teeth to some degree, there is still a considerable proportion who experience difficulties. These difficulties may result in the reduced identification of dental issues and subsequently reduced treatment by both owners and veterinary professionals (Fernandes et al, 2012; Enlund et al, 2020b). Improvements in the early training of dental homecare for the dog and education for the owner are important to reduce lack of cooperation from the dog, and to increase the performance and owner compliance with dental homecare (Enlund et al, 2020b). It should be noted that the use of toothbrushing is contraindicated in cases where it may cause pain, stress or fear in the dog, and in such cases, when improvements cannot be made with training, alternative passive methods should be recommended (Niemiec et al, 2020).
Many respondents perceived toothbrushing and chewing bones to be important for dental health and factors like special dental food, dental chews, toothpaste, and a dog’s breed as less important, which supports findings reported by Enlund et al (2020a). While it is encouraging that many owners considered toothbrushing to be important, results indicate strong support from owners on the use of bones and other hard chews, despite the risk of dental fractures or damage, foreign body obstructions and gastrointestinal upset associated with their use (Roudebush et al, 2005; Stookey, 2009; Niemiec et al, 2020). It should also be noted that many owners opposed the use of products such as dental chews and diets, despite evidence of their benefit within a homecare routine (Hennet, 2002; Logan et al, 2002; Stookey, 2009; Mateo et al, 2020). These results support the need for further owner education, specifically on the efficacy and safety of different dental homecare products, which could be provided by veterinary professionals.
Opportunities that veterinary professionals can use to deliver owner education and animal training include appointments such as annual boosters, health checks and veterinary nurse-led clinics (Ackerman, 2020). Puppy clinics provide a crucial opportunity for educating owners and training of young animals, helping to habituate puppies to having their mouths examined and teeth brushed, which may alleviate behavioural issues that impact toothbrushing in the future. Other opportunities such as postoperative dental checks and geriatric clinics can also be used by veterinary professionals to provide ongoing guidance, support and education on canine dental health to owners (Milella et al, 2014).
As results revealed that most instructions from veterinary professionals had been received by owners verbally, with few stating they had received written information or practical demonstrations, veterinary professionals might consider providing these alternative methods in clinics to increase owner recall and compliance (Loftus, 2012; Milella et al, 2014). The acceptance by the animal, and the owner, of procedures such as toothbrushing could be increased by encouraging early and sufficient training, which would also improve owners’ abilities and efficiency. These recommendations should be considered seriously in order to reduce the difficulties around dental homecare encountered by owners, alleviate time constraints and increase client compliance. Further techniques to ensure client compliance with dental homecare include recommending passive homecare products, such as toothpastes, before introducing active methods, as well as involving the owner in planning a dental homecare routine, to meet the animals’ and owners’ individual requirements (Roudebush et al, 2005; Niemiec et al, 2020).
Conclusions
There is currently a lack of adequate canine dental homecare among a sample of dog owners in the UK, illustrating that owners currently perform insufficient dental homecare to prevent periodontal disease. Further education from veterinary professionals would help increase owners’ understanding and performance of dental homecare, which could reduce the potential need for invasive dental procedures. Additional strategies, such as greater provision of dental clinics and recommendations during veterinary consultations, should be considered by veterinary practices to better educate owners on dental homecare. By using information gained from these results and the recommended strategies for improvement, veterinary professionals may be able to influence performance of dental homecare, which may reduce the prevalence of periodontal disease and subsequently improve canine dental health and welfare. The research has provided an insight into the subject of dental homecare provision from UK-based participants that mirrors research from other countries. However, further research to obtain a more geographically representative sample of the UK population of dog owners would confirm these findings.
Key Points
- Home dental care is currently under-used by canine owners in the UK.
- Strategies need to be developed by veterinary professionals to encourage the uptake of dental care at home.
- This might include identifying opportunities within existing clinics to deliver education to owners, as well as reviewing ways in which information is delivered.
- It is important to stress to owners the benefits of reducing the occurrence of periodontal disease in dogs.