Preventative dental care: educating the client

Many pets seen in every day veterinary practice have dental disease requiring treatment. It has been estimated that approximately 80% of dogs and cats demonstrate a degree of periodontal disease by 4 years of age (Harvey and Emily, 1993) Most owners are unaware that their pet has a problem, so often dental problems go undiagnosed. The role of the veterinary nurse is vital in educating clients to recognize disease but also to help institute and maintain oral hygiene programmes. Early intervention is the key to a pain free and infection free mouth.

Education is the cornerstone of preventative dental care. In order for the veterinary nurse to educate and inform clients a working knowledge of common dental diseases, disorders and problems is vital.

Periodontal disease (gum disease)

Periodontal disease is the most common disease affecting dog and cats. Up to 80% of animals over the age of three are affected by periodontal disease (Lund et al, 1999). Periodontal disease is an inflammatory and destructive condition which affects the supporting structures of the tooth (the periodontium). The cause is dental plaque but other factors, such as the host immune response, should be taken into consideration when trying to control and manage the disease.

Dental plaque is the accumulation of glycoproteins and bacteria in a polysaccharide matrix, which thickens to form a bio-film on the tooth's surface. It is sticky, with the consistency of a paste and is the cause of halitosis. It is a similar colour (yellowish) to teeth and therefore difficult to detect. It cannot be easily rinsed off from the surface of a tooth but can be disrupted by light mechanical scraping, such as tooth brushing.

Within days of plaque accumulating it becomes harmful and in some cases can start to form calculus (tartar). Calculus is mineralized plaque which in itself is not harmful but can harbor and protect plaque within its structure. Gingivitis (Figure 1) is the initial response to plaque on a tooth's surface and is the inflammation of the gingival margin, which is reversible. There is no periodontal attachment lost at this stage. Periodontitis (Figure 2) is inflammation and loss of the supporting structures of the tooth. This condition is irreversible.

Periodontal disease is not only a disease that affects the mouth but has been shown to affect the pet systemically. Both the bacteraemia and the production of chronic inflammatory mediators are thought to be responsible. Changes to the heart valves, kidneys and liver have been reported. Locally the disease causes bone loss that may result in jaw fractures if left untreated, or when affecting the maxilla, oronasal fistulae, that may also result in respiratory complications (DeBowes, 1996).

It is important for clients to realize that their pet is not just coming in to have its teeth cleaned when they are booked in for dental treatment, but to treat a disease, periodontal disease. It is also important for clients to realize that the changes are irreversible and once there has been bone loss, changes in the gingival margin and other attachment loss, this can never be replaced.

Endodontic disease

Diseases involving the pulp chamber are also very common in practice and include:

• Fractured teeth (Figure 3)

  Figure 3.Complicated fracture of the crown exposing the pulp chamber (black spot).

• Worn teeth with or without pulp exposure (Figure 4)

  Figure 4.Worn teeth.

• Caries lesion (tooth decay) (Figure 5)

  Figure 5.Upper molar affected by caries.

• Non-vital teeth, i.e. pulpitis or pulp necrosis.

Fractured teeth may result from inappropriate chew toys, for example nylon bones or stones. If the pulp is exposed, the tooth needs treatment. Worn teeth or attrition is the loss of tooth substance that may result in pulp exposure. It results from wear of the tooth from tooth on tooth contact or by an abrasive surface. The cause is usually from certain malocclusions or chewing on fibrous chew toys or balls such as tennis balls or stone chewing. Dogs should be prevented from cage biting, stone chewing and excessive play with textured balls.

Caries, although relatively uncommon, occurs in dogs. Caries lesions usually affect the occlusal (grinding) surface of molar teeth. Demineralization of the enamel occurs when plaque bacteria use sugar from a pet's diet as a source of energy, producing acids. With time, the process extends to involve the dentine, and then into the pulp, resulting in pulpitits (inflammation of the pulp) and ultimately pulp necrosis (Hale, 1998).

Non-vital teeth are seen as discoloured teeth usually following trauma to the tooth. The crown can be any colour from pink to black resulting from bleeding of the pulp and resulting haemoglobin breakdown products settling in the dentinal tubules. Studies have shown that 92% of discoloured teeth have irreversible pulpitis, requiring treatment (Hale, 2001).

When the pulp chamber in any disease process becomes comprised the tooth will require treatment, as it is a painful condition. If left untreated it can result in infection leading to pathology of the tooth root. Treatment options are either extraction or root canal treatment.

Feline odontoclastic resportive lesion (FORL)

FORLs (Figure 6) are a type of ‘idiopathic’ external root resorption, where the hard tissues of the root surfaces are destroyed by the activity of multinucleated host cells called odontoclasts. Up to 30% of cats in any population have FORLs (Ingham et al, 2001). This figure increases to 75% in cats coming into practice for dental treatment where full mouth dental radiographs have been taken (Verstraete et al, 1998). There is no known aetiology and the current treatment remains extraction. Two types of resportive lesions are seen: type 1, (Figure 7) where there is resportion of the tooth but no replacement of bone or cementum on the root surface; type 2, (Figure 8) where the tooth roots undergo resorption and are replaced with bone, resulting in spot ankylosis (loss of the periodontal ligament resulting in fusion) of the tooth with the alveolar bone. The two types can only be distinguished by radiography. Radiography also helps the client understand the disease process and why extractions are necessary.

Dental home care

The owner must understand that home care is the most essential component on both preventing and treating periodontal disease. It also gives the owner an opportunity to check their pet's teeth daily to ensure that pathology, such as fractured teeth, do not go unnoticed. The responsibility of maintaining oral hygiene, i.e. keeping plaque accumulation to a level compatible with periodontal health, rests with the owner of the pet. Home care compliance is often lost through poor follow up by the veterinary practice. This is where the veterinary nurse can play an important role.

Home care can be divided into two types:

• Active home care, i.e. tooth brushing and mouthwashes
• Passive home care, i.e. diets and chews

Active home care

The gold standard in home care is daily tooth brushing with a pet toothpaste. Brushing is the most effective method to keep teeth clean and prevent periodontitis as it allows the gingival margin and gingival sulcus to be cleaned and so reduces plaque accumulation (Lindhe et al, 1975).

It is likely that most owners have at some point been told that they need to brush their pet's teeth but do not know why or how. As a result compliance levels are poor. By giving precise information and clear instructions with good follow up, compliance can greatly improve (Miller and Harvey, 1994). If the owner also has the disease process explained to them as well as the potential benefits to their pet both locally (pain and infection) and systemically, compliance is improved with consequent health benefits to the patient.

• Tooth brushing — the owner should be instructed and shown how to introduce tooth brushing (Figure 9). Always use a medium toothbrush of suitable size for the dog or cat. Usually a human tooth brush regular size is adequate for all but the smallest of dogs. If a toothpaste is used it is essential that it is a pet toothpaste that does not contain fluoride, as pets will swallow the toothpaste and excessive ingestion of fluoride can lead to an acute, but more likely a chronic toxicosis (Gorrel, 2003). There are many texts available giving step-by-step instructions on how to tooth brush that could be printed as a useful leaflet to be given to clients (for an example see Box 1).

  Figure 9.Tooth brushing.

  Box 1.Guide to tooth brushing

  Important things to remember	Keep tooth brushing session short and sweet — around 3 to 5 minutes
  	Repeat each stage on five separate days before moving to the next
  	Every dog is different so train at a dog's own pace and give lots of praise
  Stage 1 — introducing the taste of toothpaste	1) Wash hands and smear a small amount of toothpaste on to your index finer
  	2) Allow the dog to lick the toothpaste from your finger
  	3) Repeat several times
  Stage 2 — getting used to something in his mouth	1) Smear your finger with some toothpaste
  	2) Gently rub your finger over the outer surface of the teeth and gums
  	3) Only go as far into the mouth as the dog is happy with
  	4) Repeat several times
  Stage 3 — introducing the toothbrush canine teeth first	1) Wet the toothbrush with water and smear with toothpaste
  	2) Let the dog lick some of the toothpaste off the bristles to get him used to the feeling
  	3) Gently hold his mouth around the muzzle to stop him from chewing the brush
  	4) Bridge your dog's nose and lifting the lips, gently brush the canine teeth up and down. Start angling the brush towards the gum line and brush away from the gum line to the tip of the tooth
  	At this stage, avoids the incisors, as this is the most sensitive area in the mouth
  Stage 4 — brushing the pre-molars and molar teeth	1) As before, brush the canine teeth using a up and down motion
  	2) Slowly move along the dog's mouth, using a circular motion
  	3) Only go as far as the dog is happy with
  	4) Brush both sides of the mouth
  Stage 5 — brushing all of the teeth	1) As before, brush the canine teeth, then the cheek teeth and finish with the incisor teeth
  	2) To brush the incisor teeth, hold the mouth closed around the muzzle and gently lift the upper lip with your thumb and forefinger, bridging the muzzle to reveal the incisor teeth. Many dogs will sneeze during this as they are very sensitive
  	3) Gently bush the incisor teeth using an up and down motion
  	4) Gradually build up the amount of time spent brushing
  	Tooth brushing should be performed on a daily basis for maximum protection

• Chlorhexidine mouthwashes, e.g. Hexarinse (Virbac, Bury St Edmunds, Suffolk), are a good addition to brushing as they reduce bacterial load in the mouth and have a long-term effectiveness of 12 hours. They can be used by applying them to the toothbrush instead of a toothpaste or on cotton buds to rub along the gum margin. They can also be used by syringing into the mouth, although this is not as effective as application directly on to the tooth surface. It has been reported in humans that the use of chlorhexidine mouthwashes can cause tooth staining. In dogs and cats though the advantages of its use out way this ‘cosmetic’ problem (Robinson, 1995).

Inform the owners that dental home care can be a lifelong commitment but it will reduce the amount of dentistry required in the future and benefit the pet's overall health, i.e. reductions in the incidence of disease are diminished. Review the pet regularly — fortnightly visits are recommended initially to assess tooth brushing, and then monthly to ensure that the owners feel confident with brushing and are carrying it out effectively. Once the owners are in a routine of brushing then 3 to 6 monthly check ups are recommended. Initially if the interval between visits is too long, the clients do not become bonded to the practice and the idea of tooth brushing. If they find home care difficult at this stage they will often avoid visits, possibly even move practice and may be reluctant to try brushing in the future.

Passive home care

Diets

There are several different diets on the market which work in differing ways. The flaw with relying on diets to help control gum disease is that they do not always allow cleaning into the gingival sulcus or at the gingival margin. The diets that show plaque reduction are for the whole tooth and not just the gingival half of the tooth, which is where the disease process begins (Logan et al, 2002). They are useful though and are recommended, but not as a substitute for tooth brushing.

Chews

Again there is a plethora of chews that claim to aid dental health. Most have a mechanical action and have limited effectiveness in reducing periodontal disease. They can be used in combination with tooth brushing and not relied on solely to prevent/reduce periodontitis.

Successful dental nurse clinics

All nurse clinics provide the opportunity to examine the mouth and check the teeth.

Puppy parties

It is much better if the owner and animal become used to an oral hygiene programme at an early age before any disease process starts. Young animals are also more accepting of new things. Puppy parties provide the opportunity for veterinary nurses to talk about oral care and point out the benefits of tooth brushing and preventing other dental diseases. A successful puppy party will be fun; using toys with toothpaste applied to them gets the pet used to the taste. They provide an opportunity to give out leaflets explaining how to introduce tooth brushing and a chance to invite owners back for an individual consultation to go through tooth brushing more thoroughly and re-inforce the importance of oral care. Initially puppies should become accustomed to having their mouths held, gums rubbed and teeth examined; a tooth brush should only be introduced once all the permanent teeth have finished erupting. When the permanent teeth are erupting, the gingiva may be inflamed and sensitive and some deciduous teeth may be mobile. If a tooth brush is used too early it may cause discomfort to the puppy and cause the puppy to become head shy or avoid further dental care. It is also important that pets have their mouths checked at 6 months of age to assess eruption and check for any malocclusion problems.

Geriatric clinics

Most geriatric patients will have dental disease of varying stages. Geriatric clinics provide the opportunity to show the owner on their own pet what is happening to their teeth. The use of pictures helps to explain the diseases present and what treatment may need to be performed. It is important to explain the systemic consequences of the disease to the owner and discuss the fact that their pet may be in pain, even if it is still eating. If they have any concerns about the mouth during a nurse consult, the client should be advised to book an appointment for a consultation with the veterinary surgeon to discuss any treatment required.

In the clinics the possibility of introducing home care and how this will improve the pet's health and quality of life can still be discussed. Pictures and leaflets should be provided for owners to read at home. A follow up telephone call can help after they have had a chance to read and digest the information that has been given out. The client should be reassured and time taken to explain that veterinary dentistry is important for their pet's overall health and welfare.

Dental clinics after dental procedures

Post-operative check

A 3-day post-operative check enables the veterinary surgeon or nurse to ensure that the animal has recovered from the general anaesthesia and is eating normally. It also provides the opportunity to go through the dental chart, discuss radiographs and explain why the treatment carried out was necessary. This has often been discussed at the time of discharge but at that time many pet owners are distracted by getting their pet back. Discuss the importance of home care and show the owner how to brush their pet's teeth. If some pets' mouths are still inflamed or sore after extractions chlorhexidine mouth wash on cotton buds may be more appropriate in the short term. This is also useful for cats who will not tolerate a toothbrush. Any literature (e.g. Box 1) can be given out at this check and the next recheck appointment booked for a fortnight later.

Fortnight check

This is a good time to find out how the owner is getting on brushing the teeth. Plaque disclosing solution can be used to show the owner which areas are not being cleaned. The owner should be encouraged and praised if they are doing well and help provided in problem areas if required. At this time dental diets and any chews can be discussed. If it is done at the time of the discharge or at the post-operative check it gives the owners an alternative to brushing and most don't even make an effort to try to brush. Further follow up appointments can be arranged as required, usually at least every 6 months.

Conclusion

Dentistry is one of the most important aspects of health care alongside vaccination and medical care. Dental disease can cause local as well as systemic complications. Many dental diseases also result in pain, and if left untreated, should be considered a welfare issue. A good home care regimen introduced from an early age can reduce the risk of dental disease and the need for dental treatments, although this can be challenging and time consuming to establish. It is important that the client understands the long-term benefits for their pet for this to be successful. Nurses play a vital role in educating the client and giving advice on preventative dental care such as tooth brushing and safe chews and toys. For a good oral hygiene programme to be effective and beneficial to pets, it is important that the nurse has a good understanding of dentistry and dental hygiene products.

Key Points

• Periodontal disease is one of many dental diseases affecting our pets.
• 80% of animals over the age of 3 years are affected by periodontal disease.
• Dental problems result in pain and infection and should always be treated as such — it is not just a case of ‘cleaning the teeth’.
• Educating the client is the key to preventing dental problems and maintaining oral health in pets.
• Tooth brushing is the ‘gold standard’ of home care and the best method to prevent dental disease.