When Teeth Go Bad How nurse advice can help reduce recurrences of dental disease. Callum Blair BVMS MRCVS

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1 When Teeth Go Bad How nurse advice can help reduce recurrences of dental disease Callum Blair BVMS MRCVS Dental disease is a common condition affecting cats and dogs. An often quoted statistic is that 80% of dogs and 70% of cats develop periodontal disease by the age of three years. Whilst practices have increasingly acknowledged the importance of dental disease and equipped themselves better to perform routine dentistry, the integral role that homecare should play in a dental procedure is often neglected. Normal Tooth Enamel Gingiva (Gum) Cementum Periodontal Ligament Alveolar Bone Dentine Gingival Sulcus Pulp Cavity Veins Arteries Nerve Fibres Lymphatics Connective Tissue Figure 1 Normal Tooth Anatomy In order to understand the role of Homecare it is important to understand normal tooth anatomy (Fig 1), the progressive nature of the development of dental disease (Figs 2-5) and the central role that plaque plays in this condition. Plaque In terms of gingivitis and periodontal disease, plaque is the root of all evil as it is the cause of both of these conditions. It is a soft, sticky, tooth-coloured paste-like mixture of salivary glycoproteins, sloughed epithelial cells, white blood cells and bacteria which is only clearly visible when stained with a discloser. Within hours of eating dental surfaces become coated in a layer of glycoproteins called the acquired pellicle which is then colonised by bacteria. As this immature plaque matures it becomes more organised and firmly adhered to the teeth. Mature plaque consists of 75% structural matrix and 25% bacteria and it is only as it matures that it becomes more harmful. Plaque builds on all surfaces in the mouth but more so on teeth as they have a static surface. Plaque bacteria produce various products but two of the most significant groups are volatile sulphides the cause bad breath (halitosis) and toxins which cause tissue inflammation. Plaque is the precursor to tartar (calculus) and tartar always has plaque on and in its surface.

2 Just as in human dentistry, the regular removal of plaque, particularly from the gingival sulcus, is central to the control of gingivitis and periodontal disease. Development of Dental Disease Gingivitis (1) Inflammation of the gingiva (gum margins) -red and swollen (oedematous) Plaque on the teeth is causing tissue irritation Mild halitosis Some bleeding on chewing or brushing No change in gum attachment or bone support Completely reversible with good Home care; optimum is daily brushing Swollen (oedematous) and Inflamed Gingiva (gums) Gingivitis (2) No change in Gingival Sulcus Figure 2. Gingivitis Mild Periodontitis (1) Gingivitis and inflammation of the periodontal ligament Plaque (+/- tartar) present Migration of gingival attachment leading to periodontal pocket formation Maximum pocket depths measure 3 to 4 mm in the dog or 1mm in the cat Loss of some bone at the top of the socket (up to 25% of root attachment) Breakdown of tooth support is irreversible. Disease progression may be halted by a combination of adequate dental Home care with professional periodontal treatments Gingivitis Inflammation of Periodontal Ligament Mild Periodontitis (2) Periodontal Pocket starting to form (3-4 mm dog 1mm cat) Figure 3. Mild Periodontal Disease Moderate Periodontitis (1) Deeper periodontal pockets (up to 6mm in the dog and up to 2mm in the cat) Moderate loss of gum attachment and bone support (25 to 50 %) Generally more plaque and tartar present on the teeth Often marked gingivitis with noticeable bleeding on chewing or brushing significant bad breath (halitosis) Possibly some tooth mobility Disease progression can be significantly slowed by aggressive veterinary therapy and continuous Home care meaning teeth are kept longer Moderate Periodontitis (2) Calculus overlaid with plaque Gingivitis with inflammation and destruction of Periodontal Ligament Notable loss of alveolar bone Periodontal Pocket increasing in size ( 6mm dog 2mm in the cat) Figure 4. Moderate Periodontal Disease

3 Advanced Periodontitis (1) Deep periodontal pockets (over 6mm in the dog and over 2mm in the cat) Usually severe gingivitis plaque, tartar and halitosis Advanced loss of bone support and gum attachment (with over 50% of bone support loss) Often extensive tooth mobility High levels of subgingival infection and possibly pus exuding from gums Extraction or eventual loss of the tooth are the only outcomes Advanced Periodontitis (2) Calculus Gingivitis with inflammation and destruction of Periodontal Ligament Extensive loss of alveolar bone +/- PUS Periodontal Pocket increasing in size (>6mm dog >2mm in the cat) Figure 5. Advanced Periodontal Disease As can be seen from these diagrams the later in the course of dental disease that intervention is attempted the more aggressive therapy has to be and the poorer the prognosis. Damage to the periodontal ligament is irreversible and once this has occurred, the objective is to halt or slow down the progression of disease in order to conserve the teeth. Periodontal disease is self perpetuating as the deeper the periodontal pocket the greater the amount of plaque that will be deposited subgingivally. As a consequence of these greater levels of plaque, diseased teeth are also associated with higher levels of bacteria. Significance of Dental Disease The main complaint that will cause clients to seek advice on their pets teeth is halitosis; however there are more general and significant effects that may be associated with dental disease. Periodontal disease could also be described as osteomyelitis of the alveolar bone. Diseased teeth are a site of infection which will cause a transient recurrent bacteraemia on biting or chewing. It is also recognised that dental disease can be a source of chronic pain resulting in behaviour modification that is only really identified when the source of that pain is removed. The bacteria associated with periodontitis may also be implicated in: Right-side heart failure bacterial endocarditis Liver dysfunction Renal failure Bone marrow suppression Although plaque associated bacteria have been identified in all of these tissues no confirmed causal link has yet been established. In veterinary practice the need for a general anaesthetic to perform even routine cleaning and polishing can often result in a reluctance to intervene at an early stage, however, if good quality homecare is used to follow-up the procedure then the longterm prognosis is significantly improved.

4 Homecare Homecare should be regarded as an integral part of any dental procedure and at least as important as any other post operative care or medication. It is an essential followup to in-clinic dental procedures to both maintain benefit of that procedure and conserve teeth. There are three main options for Homecare: 1. Tooth brushing 2. Chlorhexidine rinses or gels 3. Dental Diets or Treats Homecare will only be successful if good compliance is achieved, pet owners should not be expected to be able to brush their pet s teeth simply by supplying them with the appropriate toothpaste and toothbrush. In a recent paper on Homecare published in the Journal of Veterinary Dentistry the author clearly stated that inappropriate homecare could be detrimental to the pet and the owner and that it should not be regarded as an over-the-counter sale. The position of trust and respect that Veterinary Nurses have with pet owners makes them ideally positioned to provide the support necessary for successful homecare. Tooth Brushing The gold standard of dental care is daily tooth brushing as it is the single most effective method of plaque control. The benefits of tooth brushing are two-fold Abrasion physical removal of plaque Inhibition of plaque bacteria (depending on product) Only toothpastes designed for use in animals should be used as human toothpastes, if swallowed, may cause problems due to their fluoride content and the inclusion of frothing agents which can result in gastric irritation. Pet toothpastes will also improve compliance as they are designed to be more palatable to cats and dogs than mint flavoured products tend to be. Chlorhexidine Gluconate Chlorhexidine gluconate rinses and gels can be used as an adjunct or alternative to tooth brushing. If clients cannot achieve regular brushing then using them twice daily will provide approximately ⅔ of the benefit of brushing. The main properties of Chlorhexidine are (1) : 1. Very effective broad spectrum antibacterial and antifungal agent. 2. Inhibition of plaque development by binding to the acquired pellicle, reducing the absorption of further plaque components and inhibiting early microbial colonisation. 3. Cause limited breakdown of existing plaque and render it non-pathogenic. 4. Good persistence of activity as it readily binds to oral tissues one application can be effective for up to twelve hours.

5 Diets, Treats and Water/Food Additives Dental diets and treats work primarily through physical removal of plaque as food slides over tooth surface; consequently the design (shape or consistency) of the diet/treat will influence the extent of cleaning. They should conform to tooth shape when bitten into to improve effectiveness. They are not as effective as good toothbrushing as they cannot remove plaque from the gingival sulcus, the site where the main pathogenic processes occur. Recently food and water additives have been marketed which claim to have antiplaque activity. One xylitol based additive (Vet Aquadent, Virbac) has some published evidence of efficacy (2) but most of the evidence supporting these products is largely anecdotal. Diets, treats and additives should ideally be used as an adjunct to tooth brushing or chlorhexidine rinses or used as a fall-back option where compliance with other measures has proved impossible. Appendix 1 outlines two different approaches to post-operative management. The use of disclosing swabs or solutions is an extremely useful technique to demonstrate plaque to the pet owner and to target tooth brushing. Where this approach has been adopted it has proved highly motivational to both the veterinary nurse and the pet owner. References 1. ROBINSON, J. G., (1995). Chlorhexidine gluconate the solution for dental problems. Journal of Veterinary Dentistry, 12(1), CLARKE, D.E., (2006). Drinking water additive decreases plaque and calculus accumulation in cats. Journal of Veterinary Dentistry, 23(2),

6 APPENDIX 1 Two approaches to post-operative management of routine dental cases. erative management Discharge Take client through procedures involved in dental Refer to dental chart (± radiographs) Raise awareness of Homecare Discharge with Chlorhexidine rinse (+ other indicated medication e.g.nsaids) Day 3 Week 3 Month 3 Take client through procedures again Demonstrate stages of development of dental disease Give client a copy of Dental Chart and toothbrushing kit Encourage initial training success with CHX rinse/initial training Demonstrate brushing technique on client s pet Give client opportunity to try brushing under supervision for 3 month check success with brushing Use discloser to check for plaque and show client Allow client to demonstrate brushing technique Address problems If brushing not possible try easier alternative for next check 06/01/2008 CWB VICAS Nurse Dental 47 Alternative management Discharge Take client through procedures involved in dental Refer to dental chart ±radiographs Raise awareness of Homecare Provide no home-care Day 10 Take client through procedures again Use disclosing swab to demonstrate presence of plaque Demonstrate stages of development of dental disease Give client a copy of Dental Chart and toothbrushing kit Encourage initial training Week 3 success with initial training Use disclosing swab Demonstrate brushing technique on client s pet Give client opportunity to try brushing under supervision for 3 month check Month 3 success with brushing Use disclosing swab and show client any plaque Allow client to demonstrate brushing technique Address problems If brushing not possible try easier alternative for next check 06/01/2008 CWB VICAS Nurse Dental 48