I am often asked by clients or readers about specific products, and while I certainly can only investigate a small proportion of all the stuff marketed to pet owners, I try to look at as many of these things as I can. Some of my colleagues have begun using a product called HealthyMouth , a water additive reported to reduce accumulation of plaque and retard the development of dental disease. This product has received a seal of acceptance from the Veterinary Oral health Council (VOHC) and an endorsement from Dr. Fraser Hale, a dental specialist and someone who generally takes a skeptical, evidence-based approach to dental therapies. Dr. Fraser has gone from being skeptical of the product to actively recommending and distributing it. These are sources I believe are trustworthy, so I thought I ought to take a closer look at the product. In keeping with my general approach, I will review the product in terms of the following general issue:
1. Basic plausibility for proposed effect/mechanism of action
2. Pre-clinical, non-target species research
3. Clinical trials
4. Marketing claims
The product ingredients list is extensive, though specific quantities/concentrations are not provided. Only two are described as “active” ingredients, papain and zinc gluconate, but I will discuss several others that appear to be included for some specific effect. Theoretical rationales are provided for some ingredients but not others. Many ingredients are described as “organic,” which I suspect has little relevance. The dog and cat products appear from the ingredient list to be identical except for the addition of the amino acid taurine to the feline product.
1. Pomegranate- No specific claim is made about this ingredient.
There are a few in vitro trials that suggest anti-bacterial effects from pomegranate juice. There are also a number of human clinical trials suggesting anti-plaque and anti-bacterial effects for oral rinses containing this ingredient (1,2). There appear to be no clinical trials in dogs other than the two unpublished studies conducted by HealthyMouth, and no trials at all in cats. Clinical trials in humans and lab animal studies show little risk, though allergic reactions in humans have been reported, and there are some concerns about possible interference with the metabolism of other supplements or drugs.
2. Yucca- I was not able to find any in vitro research suggesting a benefit for yucca extract in preventing or treating dental disease. There have been a couple clinical trials of one yucca extract in dogs (3) and one in cats (4) reporting some decrease in the odor of flatulence, and no significant adverse effects were reported. There are reports of yucca extracts causing gastrointestinal symptoms. I was not able to find any clinical trials of yucca extract as a preventative or therapeutic for dental disease in humans or in dogs or cats.
3. Zinc gluconate- The claim made for this ingredient is that ” zinc gluconate operates as an antibacterial agent.” There are clinical trials of zinc gluconate containing rinses and toothpastes in humans which appear to show decreased plaque and gingivitis, but the compound is almost always combined with triclosan or other antibacterials, so it is unclear what role the zinc itself has in any effect seen. There are no clinical trials investigating the use of this agent in preventing or treating dental disease in dogs or cats. Excessive zinc ingestion can cause serious and even life-threatening complications.
4. Blueberry- I found one study suggesting a particular blueberry extract might have a weak effect reducing the aggregation of bacteria found in the human mouth (5). There appears to be no lab animal, or clinical trial evidence in humans or other animals that blueberry is useful in the prevention or treatment of dental disease. Blueberry’s are reported to contain substances which have anti-oxidant properties, but the clinical significance of this is unclear, and no apparent connection exists to prevention of dental disease.
5. Papain- A combination of proteolytic enzymes found in papaya, papain does not appear to have been studied extensively as an agent for prevention and treatment of dental disease, though it is occasionally found in toothpastes. I was not able to find any clinical trials in humans, or in dogs or cats regarding dental disease. There are some safety concerns as large amounts have been reported to cause perforation of the esophagus in humans, allergic reactions are possible, and there is some potential risk of reducing blood clotting function, especially in combination with some other herbal ingredients including cloves which is one of the flavoring agents in HealthyMouth.
6. Vitamins B2 and C- These appear to be included as “anti-oxidants” and to “increase the immune response.” The notion of boosting the immune system is a meaningless marketing device and while there is some preliminary suggestion that preventing oxidative damage can sometimes be a good thing, oxidation is also one of the ways the body suppresses cancer and fights infection, so it is not appropriate to assume that reducing it, even if these substances actually do that in a living animal, is a good thing.
7. Clove and cinnamon- These are apparently added as flavoring agents, and I found no research to suggest benefit or risk associated with them in dogs and cats. I wouldn’t expect them to be especially appealing to cats, but the company claims they love it.
As I mentioned, HealthyMouth has been awarded the Veterinary Oral Health Council (VOHC) seal of acceptance. VOHC is an independent organization that reviews the evidence for products claimed to have value for prevention and treatment of dental disease in animals. The organization requires clinical trial evidence to support product claims, and they have pretty specific protocols to ensure these claims are adequately demonstrated. However, I still have some concerns about the trials HealthyMouth uses to support its product claims.
As I often point out, all of us have biases about the ideas and beliefs we hold. We naturally believe our hypotheses to be true, and this can lead us to see what we want or expect to see, to focus on confirming information and ignore or minimize contrary information (e.g. confirmation bias and cognitive dissonance). And non-ideological motives, such as financial incentives, can also influence our interpretation of what we see even if our intentions are quite honest. It is well established in human medicine that trials funded by industry, for example, tend to have findings favorable to the products of the funder. The purpose of formal clinical trials is to help us test our ideas in a way that hopefully prevents these biases from inappropriately influences our findings.
It is important to be aware of the potential biases involved in a clinical study, not because this information allows us to automatically dismiss the findings but because it helps us spot weaknesses in the methods and evaluate the results in context.
In the case of HealthyMouth, the two clinical studies in dogs were both funded by the company that manufactures the product. And thought the chief investigator, Dr. Jean Dodds, is a well-respected veterinarian who has done much fine work for the veterinary profession and animal welfare, she is also a prominent advocate of “holistic” veterinary medicine, having even received the Holistic Veterinarian of the Year award from the American Holistic Veterinary Medical Association, an organization I’ve discussed frequently before. These facts are relevant because they indicate the high potential for a bias favorable to the product in these trials, and so we must look carefully at the methodology of the trials to see if there are adequate controls.
It is difficult to evaluate all the details of the methodology since the trials have not, as far as I can tell, been through peer review or been published in the scientific literature. The information I evaluated about them comes from the HealthyMouth web site. It appears that two trials, with 40 different dogs in each study and a duration of 28 days (requirements of the VOHC protocol) were conducted by Dr. Dodds in a greyhound dog rescue center and blood bank she founded and manages. The advantage to this, apart from logistics, is that the husbandry of the dogs was likely pretty uniform, which reduces sources of variation between groups. The disadvantage is that the dogs were all of one breed (and one in which dental disease is a particular problem), and the conditions were likely very different from those experienced by typical pet dogs.
The VOHC standards recommends randomization of subjects, but it does not appear that procedure was used in this study. Subjects were allocated to groups based on kennel housing so that the access to treated or untreated drinking water could be more easily controlled. This introduces some small potential source of difference between groups other than the treatment itself.
The dogs had a full dental cleaning under anesthesia at the start of the trials, and their plaque scores measured at intervals, as recommended in the VPHC protocol. A big concern about the study, however, is that there was apparently no blinding. The treated and untreated water were easily distinguished, and the staff managing the dogs and evaluating their oral health were apparently aware of which group they were in. This always introduces a strong potential for bias, and it is especially a concern in a trial like this where there is a strong presumption of safety and efficacy in advance on the part of the organizers of the trial (the company making the product) and possibly among the investigator and her staff. In any case, the evidentiary value of a clinical trial is substantially lower if it is not properly and effectively blinded, and such trials almost always find a positive treatment effect.
In any case, the trials both showed a strong positive effect on plaque scores. No trials have yet been made public in cats, and no independent evaluation of HealthyMouth appears to have been done.
As is probably inevitable, the marketing of this product involves a lot of “satisfied customer” testimonials. Stories of dogs and cats who apparently experienced great benefits are told, and of course no stories from pet owners who do not believe their pets befitted are told. This creates the impression of a safe and effective product, but of course it is a form of advertising, not a reliable source of information about whether the product actually works.
Dr. Hale gives the company founder credit, appropriately in my opinion, for marketing HealthyMouth as an adjunct to appropriate home and professional dental care, not a magic cure-all or substitute for other, established preventative and treatment methods. This is a point in the company’s favor.
Not so encouraging is the frequent use of words like “natural” and “artificial” to imply that the product must be safe. The advertising even goes so far as to claim there are “no chemicals” in the product, which is nonsense since water, blueberry juice, and every other ingredient is a “chemical.”
As I have often pointed out, botulism and uranium are “natural” and polio vaccine and penicillin are “artificial,” so these words don’t really mean what they are implied to mean. In any case, several of the ingredients have recognized health risks in humans, and most have not apparently been tested for safety in dogs or cats. And it is impossible to tell from the web site how much of the various ingredients are in the product, so no definitive statements about safety can be made. I would be surprised if there are any significant risks from the product since it would require an awful lot of most of the ingredients to be dangerous as far as I can tell, so I’m not especially worried about the safety issue. But the claims of safety are really assumptions based on the naturalistic fallacy, and supposedly safe herbal and homeopathic remedies have turned out to be harmful in the past (e.g. cinnamon bark and homeopathic belladonna), so at least a little caution is appropriate.
There are some very limited in vitro and human clinical data to suggest it is plausible that the ingredients in this product might have some benefit in preventing dental disease. The only research actually testing the product in a veterinary species (dogs) showed benefits, but some caution is warranted in interpreting these results because they are unpublished, industry-funded trials with a lack of robust methodological controls for bias and other non-treatment effects. There is no significant evidence of any real risk from the product, though it doesn’t appear that most of the ingredients, alone or in combination, have been tested for safety in cats and dogs. The company generally markets the product in a responsible way, though it does make use of some misleading advertising strategies such as promotion through testimonials and invocation of the naturalistic fallacy.
Overall, I am inclined neither to recommend the product nor to recommend against it. I applaud the company for taking the first steps in conducting the research necessary to obtain VOHC approval, and I hope additional research, ideally independent and better designed, is eventually carried out to further clarify whether this product has real safety and meaningful efficacy. I agree wholeheartedly with the company that dental disease is a serious condition and that most pets do not receive adequate preventative care or treatment, so I hope additional research does eventually show this product to be a useful adjunct to other oral care practices, but I think it the case has not yet been effectively made.
Have been using this product for 2 years now and am sold on it. My cat had a few teeth out ($1000 )when I took her to have teeth cleaned at vet for first time. I felt very bad as I thought special dental foods were doing the trick and cleaning her teeth regularly was over the top difficult. Since then I use 1.25 ml product using a syringe in 250ml water and change the water every 2 to 3 days or when empty. A notable difference to the water bowl is that I notice it does not have a slippery/slimey residue any more when I clean it which must mean the healthy mouth must be prohibiting bacterial growth. I must confess that I have also put an effort into cleaning her teeth every 3 days with a tiny brush (no paste) which I do out of guilt. I am only a third through the 245ml bottle that I bought 2 years ago and the expiry date is upon me, so it is great value for around $100. Anyway last week I took my cat to vet for free dental check and vet asked me if cat had just had vet clean under sedation elsewhere as not even a bit of plaque present (no calculus) to which I happily replied that I was doing everything possible to avoid another bloody $1000+ bill! Thumbs up to healthymouth and me!
“I must confess that I have also put an effort into cleaning her teeth every 3 days with a tiny brush (no paste) which I do out of guilt”.
If I had to guess I suspect this is doing the most good. Plus that professional cleaning must have gotten rid of all the potential problem teeth (extractions).
I went through this with a small breed dog years ago, he had a thorough cleaning and extractions at age 5, he never needed a professional cleaning again and lived another 11 years.
I did brush his teeth (what he had left) at least 3 times per week. I was brushing them prior to the cleaning too, but you can only do so much to combat genetics/periodontal disease.
Thanks for you frank summary!
I was researching something for my senior, diabetic pup‘s horrible breath, that can run anyone out of a room in seconds? and stumbled across this feed. He cannot be put to sleep anymore, and in his old age, refuses to let me brush. Anymore research done on this product in the last 9 years???
Nope, the original research is all we have. Subjectively, I have not been impressed with its effectiveness in my patients, but I am not aware of any research studies. You might want to check the other options available on the VOHC list.
We started using Healthymouth on our Poodle mix just over 2 yrs ago. Our Vet‘s recommendation he does not sell the product. Our dog was 10 yrs old at the time he said our dog was getting to old for regular cleaning that would be his last. We tried it and noticed his breath improved after a few months. He’s now over 12 years old and still has all of his teeth and they are in great shape. He won’t let us brush his teeth but he loves the water additive. We are sold on Healthymouth I’ve seen it work. I would buy it just for his good breath.
Paid $120 for Healthy Mouth for 2 cats and a dog. It does NOT work at all. Don’t waste your money.
healthy mouth reminds me of the dog dental vaccine that did not work Pfizer was selling. The dog dental vaccine finally got pulled off the market after the boarded dental veterinarians soiled themselves for recommending it. Why is the government allowing people to make money selling something like this without two independent RCT studies showing it works?
a rct should include surgery. A study shows when the parachute argument
, that you do not need a randomized controlled trial for everything, is used the treatment is worthless most of the time. Its more unethical not to do a sham surgery that to do a unproven surgery. see
I have also found that my dog’s breath is much improved using this product, which would seem to indicate some benefit as the odor is caused by bacteria. It’s very expensive but worthwhile to me if it’s helping my pup. I will add that we have been terribly noncompliant with brushing and I need to make a resolution to develop this brushing routine.
Another dental-related product, Greenies come to mind. It seems to also be approved by the VOHC.
I do brush my dog’s teeth daily. However, is there research to indicate a good amount of effectiveness to include this type of dental chews or should we just stick to solely brushing or dental cleaning?
(Really appreciate the research and knowledge you’ve shared on the blog).
Brushing and professional cleaning are absolutely more effective than any of the products on the VOHC list, so they should be the priority. It isn’t clear if these have additional benefits added to bursting and prophylaxis, but it’s possible.
Hi I realize this is a very late response but due anyone reading this they need to know.
The only proven to be effective treatment for stomatitis is a full mouth extraction (FME). The fact that you started HM at the same time as the FME doesn’t prove HM works, it’s the proven benefit of treating stomatitis with the FME in the first place.
No teeth = No tartar = No Plaque = No inflammatory response to it forming on the teeth in the oral cavity.
This is my understanding of it anyway. Context: was a client of Dr Hale in Dec 2016 having known nothing about all of this, my luck would be to pick the Persian kitten with juvenile gingival stomatitis. Saw Dr Hale in his 8 month birthday for FME, made 100% recovery in 2 weeks. Prior to that, he was diagnosed at 5 months old, went on buprenorphine 2-3x a day just to barely eat (important at that age for development) + one week on/one off of immunomodulator (interferon). He’s been pain free ever since, was well worth the 10 hr round trip and the estimate was way more than the actual fee at the end of the day in case anyone is super worried about that part (I get it). In fact today he’s more over than under weight, the ol’ ginger cream porker beano.
From my understanding toothpaste is useless unless it’s enzymatic which CET brand is. It helps to break down the tartar and freshen breath if I recall correctly (haven’t checked since 2016 when my kitten had to go through Full Mouth Extraction for juvenile gingival stomatitis with Dr Hale).
Actually, this is not true. The most effective prophylactic measure is brushing, which removes the biofilm that leads to periodontal disease. Calculus itself isn’t that significant. Toothpaste is not as important, though chlorhexidine may be of some value in reducing bacterial numbers. Mechanical cleaning by brushing is the most important measure we can take at home.
I adopted our little rescue girl 5+ years ago along with a mouthful of bad teeth. Got that mouthful of bad teeth taken care of and I have been brushing her teeth every day since, as well as having her teeth cleaned annually. She just had her teeth cleaned after 9 months (my call) and the vet says she will now need a cleaning every 6 months if I want her to keep the teeth she still has, which I do. In the meantime, the vet sold me some HM to try until then. I’ll let you know if it works. Both dogs seem to like it and haven’t suffered any adverse reactions to it. I’m willing to try anything to keep her mouth healthy and her breath tolerable. I brush her teeth with Pet Smile, another VOHC approved product.
Good lord. I’ve been pulling my hair out trying to find how I can buy this product. Should’ve checked Sketpvet long ago. Trails conducted by Jean Dodds? Nuff said. Moving on!
Anyone have tips for getting a toothbrush anywhere near the back molars of a cat who acts like I’m trying to kill her if I try to just gently pull her lips back to see her teeth, never mind actually touching them?
Have you reached any conclusion regarding Healthy Mouth and efficacy? Here we are ten years later with vets still recommending it…
No additional research. Some folks at my practice who were initially very bullish on it have stopped using it since there was no consistent sense among owners or staff that it did very much.
Any chance you would be willing to talk about water additives that may have efficacy…if there are any? I brush his teeth 3-4 times per week but cannot reach the back ones and recently he had to have some pulled. Looking mostly at the Oxyfresh and Nylabone brand water additives since HealthyMouth sounds like a no-go.
Just a testimonial – We adopted 4 year old sibling cats. Our vet recommended Healthy Mouth. In the almost 6 years we have had them they haven’t needed to see a vet for dental problems at all, not even cleaning. Our previous cats lived to be 18 & 19 years old & we spent a lot of money getting their teeth cleaned every 2 years. Healthy Mouth is a bargain!
Healthy Mouth is a bargain!>>>>
thats what the boarded dental vets said about the Pfizer usda appoved conditional use dental vaccine that finally got pulled of the market. If there was something you could put in the water or a shot you could give that kept you from needing to brush your teeth twice everyday and have deep cleanings when your gums got infected someone would have already made a billion dollars selling it to human.
Anecdotal: If a true safety issue was discovered that’s the only thing that could get me to stop using HealthyMouth. I started using it with my puppy at 9 months because she had obvious tartar building up on her back teeth and she has tight lips – brushing her teeth wasn’t very effective back there and was upsetting to her. At 13 months she has NO tartar build up, snowy white teeth, and healthy gums. And no objections to HealthyMouth – she gets some with her kibble mixed with water, and some in her water dish and eats/drinks normally. I follow the directions on the bottle for total amount to use.
Hi Tylersmom, we’ve had to use a combination of: feeding meals in two parts: first part is the seniors dry pet food, and second art is the dental food in a separate bowl. A tiny sprinkle of Troy Plaque Off (need to check for label dosage & safety) on the nightly dental food along with using the Healthymouth in water, has all helped reduce our dog’s dental problems alot, but still need to try to brush his teeth. Had to start using digesticare with a spot of veg & a little water on nightly first part of seniors food as well, for tummy, before having last nightly dental food… goodluck
Hi, I just found this article as I was searching for data on “HealthyMouth” for a summary article I am writing about at home dog dental care.
I purchased HealthyMouth gel for my miniature poodles and have some specific observations I want to share. First of all, there are three potential active ingredients: The Papain and the Zinc mentioned above And also Trisodium Pyrophosphate, an anti-tartar chemical added to some human toothpastes. Chemically, I assume that it works like hexametaphosphate to interfere with calcium matrix formation that is part of the formation of tartar. (Not sure if the comma between the words Trisodium and Pyrophosphate on the gel label was intentional to try to disguise that TP is a component– There are online articles about the chemical TP an its toxicity at high concentration but if one thinks the two words are distinct entities then the fact that this is a “chemical” and an “unnatural” active ingredient and has a rap sheet will go over the consumer’s head)
The active ingredients TP (or hexametaphosphate), Zn and Papain (or other proteolytic enzymes) can be found in a myriad of other pet dental products so nothing special here. But, of course, it could be that HM company has composed superior formulations that are more safe, palatable and effective than other companies. It may be that they simply made a delicious flavor for water that encourages greyhounds to drink more water after eating their kibble thus rinsing their teeth after meals (and the active ingredients played no significant role in the reduction of tartar observed in their small, biased, in-house, non-randomized study)
Note on the gel: It is a terrible product in my opinion (I don’t like the idea of water additives and so don’t use them because my dogs allow me to apply product directly to their teeth). The gel does not cling to teeth as the company claims, not even for a second. It does not cling at all to an applicator or a finger for that matter. In my opinion, HM company added Xanthan Gum to gel their ingredients without any research or testing. Regardless of whether or not they have an effective combo of active ingredients in this gel, they bungled the formulation such that the active ingredients don’t have a chance in practical use. They sell it for $65 because they can claim that their water additive has VOHC approval.
They sell it for $65 because they can claim that their water additive has VOHC approval.>>>
i think its a federal government failure regulatory problem. Healthy Mouth cannot be labeled for human consumption and still the makers want us to think it works for people. If the federal government can keep me from adding it to my caffeine free coffee then the fda can keep it off the market until its proven safe and effective for dogs. You can get a boarded vet dentist group to approve just about any placebo if enough money is involved and the profession does not have a easy solution to the health problem. Good example is the usda approved a dental vaccine Pfizer came out with that has been pulled off the market because Pfizer never could prove after being sold for years by vets it was efficacious. If Pfizer had a dental vaccine that worked they would not have wasted their time making one getting usda approval for dogs first. Pfizer would have come out with a fda approved human dental vaccine first. Sometimes drug makers, when they have a product that works for pets and humans, will change molecule a little bit so they can get approval for the dog and one for the human. A human dermatologist client of mine told me they did that for Apoquel so they could sell Apoquel for less than 3 dollars a pill and sell the slightly changed human form for magnitudes of money more for humans who have lots of money or insurance. If the human has no insurance the dermatologist told me some human dermatologist will tell them about dog apoquel. So now we have people taking dog medication because they cannot afford the human labeled pill.
I have a 4 yr old Westie (known for bad teeth) who had tartar forming on her teeth around age 1. I had tried to scrape the tartar off her teeth at the gum line with a scaler with only small success. I was brushing every day and Vet recommended Healthy Mouth so I bought it. About a month after she started on Healthy Mouth I got the scaler and the tartar on both upper canines came right off! I had some success w/her back teeth as well. She’s been on Healthy Mouth now for almost 3 years. I still brush daily and she has slight tartar on her back teeth but canines are clear. It seems to help so I continue using it and I’ve seen no side effects from her drinking it.
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Some Human toothpaste often has a gingivitis label on the box. Anecdotally decades ago the pet toothpaste i was selling suddenly did not seem to be working in my patients. I found out later the pet toothpaste maker took the fluoride and who knows maybe other stuff out during a human fluoride scare that was in the news at that time. What level of evidence do we have for the advice in the study above when treating gingivitis to use pet tooth paste not human toothpaste when that human toothpaste has a tested gingivitis label? Any toxicology reports of cats getting fluorosis? Does pet toothpaste without fluoride have any proven benefit beyond maybe taste? If so is that study online or behind a paywall? Are veterinarians in the UK even allowed to sell human toothpaste when a pet toothpaste is sold on the market? Children ingest toothpaste with fluoride in it when they first learn to brush. In the USA, dentist were using fluoride varnish in children and causing fluorosis in their teeth which lead to the human fluoride scare. Found it interesting that Feline Leukemia virus is so uncommon now it was not even on the list as common causes in the study above.
Same thing happened with my GSD. After urinalysis, blood was found. So far, a course of antibiotics has helped the incontinence but she is still seeming a bit off. She also started to consume large amounts of dirt. I cannot tell if this is something specific to giving healthy mouth but it started at the time.
Eventually she would go to other water bowls in our home to get water with no healthy mouth.