Educating pet owners beyond the gumline

Introduction

As we continually improve the quality of life in our pets, preventative healthcare is a leading focus of contemporary small animal veterinary medicine. A preventative approach acts as the core safeguarding measure to reduce the prevalence, severity and impact of various diseases. Oral health holds the current spotlight in preventative healthcare, and as demonstrated with consistent approaches to vaccinations and antiparasitic medications, effective pet owner education delivered by veterinary nurses/technicians is a crucial component in encouraging compliance 1.

Periodontal disease

Both canine and feline patients can present with a variety of oral health issues that are regularly overlooked, because many animals are highly skilled at masking oral pain. Inadvertently, many owners assign specific changes in a pet’s behavior with their animal’s increasing age rather than an oral health issue 2. The perception of pet oral healthcare amongst owners is therefore relatively low, whilst the prevalence of oral health issues remains high. While the exact statistic varies between reputable studies, the principal oral health issue in small animals, namely periodontal disease, is frequently cited to occur in approximately 90% of dogs over 1 year of age and 70% of cats 3 years and older 3. Smaller dog breeds and oriental breeds of cats are particularly susceptible.

The pathogenesis of this condition concerns the inflammatory destruction of the periodontium (a collective group of tissues including the gingiva, cementum, periodontal ligament and alveolar bone), which in a healthy state serves to anchor every tooth root within an individual alveolar jawbone socket 4. The tooth’s coronal surface is protected from minor acidic abrasion by an extremely thin coating of salivary glycoproteins known as the pellicle. Unfortunately, the pellicle layer attracts oral bacteria which accumulate on the tooth surface alongside food debris, fostering a plaque biofilm. Progressive mineralization of persistent plaque creates bacteria-rich calculus deposits across the tooth surface (Figure 1) 2. The intensifying burden of bacterial toxins triggers a localized inflammatory response (i.e., periodontitis) which gradually destroys periodontal tissues, resulting in advancing dental attachment loss.

The severity of periodontal disease can be objectively graded (Table 1) to standardize patient monitoring and identify suitable treatments. Of the five grades, stage 1 (established gingivitis) is commonly referred to as the precursor stage because there is no defined attachment loss threatening the dentition. Gingivitis is therefore manageable and can be reversed with effective oral healthcare measures if detected at this point 5.

Table 1. Identification of Periodontal Disease (adapted from 11). The staging refers to a single tooth, and hence categorization may be complicated by the fact that a patient’s teeth can vary in their degree of periodontal disease.

Oral care clinics

Veterinary clinics can readily provide owners with skills and techniques for monitoring and maintaining their pet’s oral health. However, time and financial pressures are two of the largest constraints on the ability for practices to meet demands. Oral Care Clinics, delivered as a dedicated veterinary nursing service, can often overcome this barrier and significantly relieves team pressures via appropriate delegation 6. Such clinics also enable veterinary nurses/technicians to fulfill their role and achieve greater job satisfaction. Therefore, veterinary nurses/technicians should fully understand the etiology and pathogenesis of common oral health conditions by accessing an abundant and growing catalogue of training resources 1,5.

Overcoming barriers

An oral care clinic appointment aims to assess the patient, outline recommendations and provide owner training. However, a commonly encountered barrier when providing any preventative healthcare strategy is encouraging attendance for an initial appointment. This issue is particularly amplified with oral care clinics, because – as noted above – where an oral health problem is not readily perceived, a solution is equally not often sought. Educating owners about the importance of maintaining their pet’s oral health is therefore strongly recommended from their initial practice visit. Veterinary nurses are often involved in the consultations for primary vaccination courses, enabling the nursing team to lay oral healthcare foundations at these appointments 6. Simultaneously, subsequent oral care clinics can be recommended either as standard practice or if more advice and support is required. Practice social media platforms are also a valuable digital marketing tool to raise awareness on pet healthcare and to advertise oral care clinics.

Many owners of adult animals will regularly attend consultations with their veterinary surgeon for booster vaccinations, health checks and medication reviews. These appointments offer a prime opportunity to consistently incorporate a conscious oral examination and assess every patient’s suitability for an internal oral care clinic referral 6. Where required, the veterinary surgeon can also diagnose oral health conditions, including periodontal disease, prior to scheduling dental procedures or oral care clinic referrals where appropriate. This is important, as veterinary nurses/technicians are usually (depending on their country’s legislation) legally unable to form a diagnosis. The frequency of these referrals and oral care clinic attendance can be tracked through practice management systems to review clinic performance.

Patient history

Veterinary nurses/technicians should firstly retrieve the patient’s recent history. For a coherent approach this should be performed regardless of whether the clinic is an initial appointment or a review. The questions for an owner should always focus on identifying both gradual and sudden changes in their pet’s behavior, as shown in Table 2.

Table 2. Points to identify in patient history during an oral care clinic.

Orofacial examinations

An effective orofacial examination is a prerequisite for every oral care clinic, provided it is safe to perform and does not induce unnecessary patient stress or discomfort that could result in future reticent behaviors 7. Some animals may only tolerate the close proximity of their owner, who may be able to perform the examination with clear guidance from the veterinary nurse/technician 2. Using a readily accessible guide for identifying common oral abnormalities (Table 3) is a useful approach, and all abnormalities should be accurately recorded using the modified triadan dental numbering system.

When examining intraoral anatomy in cats, small dogs or nervous patients, cotton swabs and tongue depressors can be utilized instead of fingers and hands to safely retract the patient’s lips and cheeks and provide greater visualization (Figure 2). Each step of the orofacial examination, alongside any concerning areas, should be communicated with the owner to deepen their understanding, awareness and involvement.

Table 3. Orofacial examination guide.

Plaque disclosing solutions applied along the tooth surface are extremely beneficial for highlighting current plaque accumulation to owners 6. Repeat application in future appointments can assess the efficacy of homecare techniques alongside regular photographs of the patient’s mouth to track any improvements or disease progression 5. Relevant resources such as case studies and anatomical models are also beneficial for owners to view in comparison to their own pet (Figure 3). These methods provide motivation for owners and opportunities to engage in further targeted discussions.

Oral homecare – Toothbrushing 

Oral homecare techniques are to be recommended in order to limit plaque and calculus accumulation that otherwise leads to periodontal disease. Various products exist and exhibit varying degrees of efficacy; the type of recommended product often relies on the patient’s temperament, history and relevant findings of the orofacial examination, alongside owner availability, motivation and technique.

Brushing of the teeth using a soft bristled toothbrush is the most effective homecare strategy, hence it is very heavily marketed in human dentistry 5. The actual mechanical brushing action is more important than the use of toothpaste for removing plaque, although brushing is generally tolerated for longer, increasing plaque removal, when using pet-friendly toothpastes with meat or fish flavorings 8. The introduction of toothbrushing from an early age increases long term compliance from both pets and owners, as younger animals are more readily accepting of new experiences 5. This reinforces the proposal to target primary vaccination appointments with oral healthcare education. Furthermore, a strategy to gradually introduce daily brushing strengthens the likelihood of compliance.

Owners should begin for the first few days by encouraging the pet to sniff and lick the toothpaste from a toothbrush or finger until accepted. The next stage requires owners to gently lift their pet’s lips and rub the toothbrush (with toothpaste pushed into the bristles) in a circular motion along the buccal surfaces of the largest teeth 5. Using a 45-degree angle directly targets the gingival sulcus; this can be demonstrated during the clinic using anatomical models or with the pet directly (Figure 4) 8. More teeth can be brushed as owner experience and animal familiarity develops over the coming weeks. Some animals will tolerate gentle opening of the oral cavity to brush the lingual aspects of the teeth too. Electric toothbrushes are not recommended, as the extra noise and vibrations can negatively impact pet acceptance.

Maintaining healthy gingiva requires daily toothbrushing; however, some brushing is better than no brushing at all 4. Owners should be encouraged to set smart phone reminders to inspire consistent brushing habits, or even store their pet’s toothbrush in their bathroom as a visual cue when brushing their own teeth. It is important to advise owners to offer their pet a reward after toothbrushing in the form of treats, toys or exercise. This may seem counterintuitive in relation to treats, but greater quantities of plaque will be removed during effective brushing compared with plaque arising from a single treat.

Oral homecare – Adjuvant therapies

Various products exist that can be used either as adjuvant therapies for toothbrushing or as substitutes where brushing is not tolerated by the pet. These methods are less effective than brushing, and it is the veterinary nurse/technician’s responsibility to educate owners on this. Ultimately the choice of product remains with the owner, but veterinary professionals should seek to specifically recommend products that feature the Veterinary Oral Health Council (VOHC) seal of approval on their packaging, which offers confirmation of evidence-based efficacy (Figure 5) 9.

Specifically formulated dental diets are designed to maximize the self-cleansing effect of chewing with long-term use via the kibble’s size, shape and texture 9. Calculus formation is reduced even further with dietary binding agents that trap salivary calcium. Food and water additives have similar functions to maintain oral health, require minimal effort to use, and can also be continued when brushing is temporarily paused following dental extractions 2. Gradual or early introduction of these products is recommended – especially with cats, who are notoriously cautious about unusual aromas in their food or water sources. Product suitability is also important; for example, the high iodine content of seaweed-based products is not appropriate for patients with thyroid issues 10.

Daily dental chews are very commonly used by dog owners as low-cost treats, as they generate a positive pet-owner reaction and exert a similar mechanism of action to dental diets 4. Whilst many manufacturers have now developed lower calorie dental chews, owners need to be shown how to factor this calorie content into a pet’s daily calorie intake to avoid excess weight gain. The size of dental chews should also be raised with owners in order to mitigate the risk of choking.

Oral homecare – Toys

The appropriate firmness of any dental chew, treat or toy is fundamental to reduce the potential for dental fractures. Suitable products can be identified by a slight indent using a thumbnail (Figure 6); this will rule out commonly used products containing hard plastic, antler or bone 2. Caution should also be aired over the use of tennis balls – despite their popular use – because the fur coating traps sand and grit which contributes to significant dental wear facets. Smoother surface balls that can be regular cleaned are highly suitable alternatives.

Follow-up services

Subsequent oral care clinics can be scheduled on an individual basis to monitor the patient’s oral health and review owner compliance with any recommendations 8. Appointment scheduling may be required more frequently until the owner feels confident with their pet’s oral healthcare, or until an oral health condition improves. Prompting owners to numerically rate their confidence with toothbrushing at each visit can help to identify further support requirements. It also enables owners to reflect and encourages attendance for the next scheduled appointment.

Where appropriate, veterinary nurses/technicians can also provide follow up support via email to provide owners with a summary of the attended oral care clinic and digital resources for the owner to access at home 7,9. This approach should take into account the different learning styles among pet owners to maximize clinic impact.

Note that oral homecare measures should not be viewed as a replacement for regular scaling and polishing, because this procedure provides effective cleaning of the gingival sulcus – the chief location for arising periodontal disease. Recommendations for the procedure at 2–3-year intervals during the oral care clinic may be more readily accepted by owners when likened to human dentistry schedules 1. As this requires general anesthesia in veterinary patients, many owners are wary of the anesthetic risk and associated costs. However, inclusion of this procedure in preventative healthcare planning aims to reduce the reliance on dental surgery later in the animal’s life, which can encompass complex dental extractions and lengthier procedures, significantly increasing both overall cost and anesthetic risk.

Conclusion

Despite the high prevalence of periodontal disease, a range of products and procedures are available to encourage preventative oral healthcare in our pets. Oral care clinics provide a valuable opportunity for veterinary nurses/technicians to impart a wealth of appreciation, knowledge and skills in this healthcare focus which owners can utilize effectively to protect their pets beyond the gumline.