A reader recently asked me about the evidence supporting recommended therapy for dental disease in dogs. This is has become a common question given the increasing awareness among pet owners that dental disease is a real and important health problem, and the availability of high quality prophylaxis and treatment.
The American College of Veterinary Dentistry, the organization of board-certified veterinary dental specialists, has a great site with information for pet owners about dental disease. I also find a lot of clear and pretty evidence-based information on the site of Dr. Frasier Hale.
Dental disease is unquestionably common, with some research suggesting it is the most common disease in pet cats and dogs, vying with obesity for the top spot. It primarily takes the form of periodontal disease, and unfortunately it is very difficult to detect or evaluate the severity of this problem in an awake dog. Dogs and cats show few overt symptoms of dental disease. Probing of the tooth sockets and x-rays are necessary, just as they are for humans, to accurately characterize the type and severity of dental disease and determine the appropriate treatment.
Unfortunately, our pets almost never get twice daily brushing and flossing or semi-annual dental cleanings, and they often have very abnormal occlusion (the arrangement and interaction of the teeth in the mouth) as a result of breeding. Toy breed dogs and those with foreshortened faces are at especially high risk of severe dental disease due, in large part, to the same anatomy that makes them appear cute to humans. So proper diagnosis and treatment of dental disease requires general anesthesia, and it is very often necessary to remove infected teeth because the disease is advanced or because the level of care needed to preserve them cannot be accomplished.
Naturally, owners are often anxious or reluctant to pursue care that involves general anesthesia and likely extraction of teeth, due to worries about the safety and comfort of the pet and also due to the high cost of appropriate care. The fact that our pets rarely show recognizable symptoms, even with a level of disease that we know would cause tremendous discomfort in people, also makes it more difficult to convince people that dental care is necessary and beneficial for their pets. While the most obvious reason to pursue this care is that the disease is almost certainly painful, it is sometimes helpful to consider the secondary health risks associated with untreated periodontal disease. I recently took a quick look at the evidence concerning these.
There is pretty strong evidence in humans that untreated periodontal disease is associated with other health problems, notably cardiovascular disease, diabetes, respiratory disease (including infections) and pre-term low-birthweight deliveries. Treatment of periodontal disease leads to clinical improvements in several diseases as well. It is plausible that a similar relationship between dental disease and general health would hold true for cats and dogs, but there is little direct evidence.
At least two studies have identified pathological lesions in specific organs, including the liver, kidneys, and heart (1,2). This demonstrates that periodontal disease is associated with detectable abnormalities in the tissues of these organs. It seems likely that this could also affect the function of these organs and the well-being of the individuals with such lesions, but this was not evaluated Β by these studies.
At least one study has taken the next step and evaluated the association between periodontitis and actual disease in another organ system (3). A strong, linear association was identified between dental disease and chronic kidney disease, and while this does not prove dental disease causes kidney disease, it suggests that untreated periodontitis may be an important risk factor for kidney disease in dogs.
A similar study also suggested that periodontal disease may be associated with cardiac disease as well as pathologic lesions in the heart (4). However, there were significant methodological problems with this study, and other investigations have not found a link between dental disease and heart disease in dogs, so there is still controversy about this potential association (5,6).
Finally, one study has looked at common bloodwork variables and measures on inflammation in association with periodontal disease and its treatment (7). A few significant associations were identified, but there was no clear pattern suggesting a causal relationship between periodontitis and any particular disease.
Bottom Line
Dental disease, especially periodontal disease, is very common in dogs and cats. Though affected pets rarely show obvious or severe symptoms, periodontal disease is undoubtedly a source of significant discomfort. The only accurate way to diagnose, characterize, and treat periodontal disease is with a thorough oral examination, dental x-rays, and appropriate cleaning and often extraction or endodontic treatment of infected teeth. This can only be accomplished under general anesthesia.
There is good reason to believe proper prevention and treatment of periodontal disease makes dogs and cats more comfortable. In humans, it is also clear that such prevention and treatment improves health and reduces the risk and severity of other specific diseases. It is likely this is also true in dogs and cats, but the current research evidence regarding this claim is extremely limited.
References
- DeBowes LJ, Mosier D, Logan E, Harvey CE, Lowry S, Richardson DC. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996; 13:57-60.
- Pavlica Z, Petelin M, Juntes P, ErΕΎen D, et al. Periodontal disease burden and pathological changes in organs of dogs. J Vet Dent 2008; 25: 97-105.
- Glickman LT, Glickman NW, Moore GE, Lund EM, Lantz GC, Pressler BM. Association between chronic azotemic kidney disease and the severity of periodontal disease in dogs. Prev Vet Med 2011; 99: 193-200.
- Glickman LT, Glickman NW, Moore GE, Goldstein GS, Lewis HB. Evaluation of the risk of endocarditis and other cardiovascular events on the basis of the severity of periodontal disease in dogs. J Am Vet Med Assoc 2009; 234: 486-494.
- Pavlica Z, Petelin M, Juntes P, Erzen D, Crossley DA, Skaleric U. Periodontal disease burden and pathological changes in organs of dogs. J Vet Dent. 2008 Jun;25(2):97-105.
- Peddle GD, Drobatz KJ, Harvey CE, Adams A, Sleeper MM. Association of periodontal disease, oral procedures, and other clinical findings with bacterial endocarditis in dogs. J Am Vet Med Assoc. 2009 Jan 1;234(1):100-7.
Β - Rawlinson JE, Goldstein RE, Reiter AM, Attwater DZ, Harvey CE. Association of periodontal disease with systemic health indices in dogs and the systemic response to treatment of periodontal disease. J Am Vet Med Assoc 2011; 238: 601-609.
Oh great, the day before I have to go to the dentist myself π
I’ve had more than my share of dental work, but every time I think how much worse it would be without it! Good luck.
Interesting how the same things happen in dogs/cats/humans. My dog is diabetic, taking insulin 2x a day, and I’ve been wondering about dental work on him. The only drawback is he is a 15 year old dog, and the vets say that anesthesia on an older dog is more dangerous. I guess time to get out the Poultry Toothpaste that we have the new kitten on, and start brushing his teeth.
Evidence based human dentistry is a good read. Polishing is done for non medical reasons, suture after extraction questional, dental cleaning without gingivitis evidence is like the annual exam with unproven promotion, treating cavities with floride rather than fillings, use of antibiotics before and after, silver filling that last longer than new white ones, use of sedation rather than anesthesia in mentally challenged patients and putting teeth back in that have been ripped out all are good reads when one looks for evidence. Attempts in Florida to require dental X-ray machines for pets got no where. Imagine deep cleanings and extractions in human medicine with no X-ray documentation. What vets need is a test for dental pain.
Art Malernee Dvm
Art said: “What vets need is a test for dental pain.”
Beyond xrays, (limited) exam, appearance and flinching by the pet in pain, drooling, anorexia, grinding teeth, head tilting etc, what more could there be?
Word on the street the boarded dental vet pulled out of this study when he did not agree there was no pathology missed. I loose a lot of clients because I do not do the “proprietary move”. I had my dentist do a root clean on one side of one tooth of mine and it hurt without a local anesthetic. The study needs repeated ASAP and the controversy about pain somehow addressed.
http://www.ivcjournal.com/research-studies/professional-outpatient-preventive-dentistry-popd-can-it-be-done-safely-and-effectively-without-the-use-of-general-anesthesia/
That is fascinating. I’d love to hear what the boarded dentist had to say. I was just at the human dentist myself a few weeks ago for my first cleaning in 2 or 3 years, and even though I had no gingivitis or visible tartar, routine hand-scaling of the subgingival tartar was extremely uncomfortable, and the tartar was so significant that it required two separate sessions. I wouldn’t do that to an animal.
Once we collated the raw data there was a significant amount of pathology missed on their side. Unfortunately we could not agree how to interpret the results and after three revisions of their manuscript I asked them to take my name and association off the study.
Maybe dental issues could have a revisit, been a while since you covered them. I’m wondering about your opinion on Oravet Chews (and generally delmopinol vs other chews) versus standard brushing, etc. Thanks again for the great blog and work!
did the vet school at Pennsylvania ever finish the anesthetic free dental study? All we have is the positive prospective study Jan bellows did that ended in a food fight with others in the study.
Thanks, I’ll add this to my list of future topics.
Chlorhexidine is considered the Gold Standard for topical oral disinfection.
Chlorhexidine was removed from the Veggie chews made by Virbac and it did not change the VOHC approval. I have lost even more confidence in VOHC approval. VOHC said the change in formula would not change approval.
I brush my dogs teeth every day with excellent results, however, my 9 pound 8 year old has a bad tooth in the back, it’s loose and causing some pain….
I have an appointment for Wednesday for a quick extraction (the rest of her teeth look pristine) I am a little nervous because the vet says he will use gas as it will be a 10 minute procedure. Is this okay? I guess I’m just looking for a little reassurance.
She went through this about a year ago, but I got lucky and the tooth fell out, root and all, on it’s own! I am hoping this may happen again before Wednesday. Any thoughts from the vets out there? Thanks in advance.
I love this site and find it extremely helpful π
Ps: I just moved the appointment for the extraction up, going in on Monday.
Update
All went well!
This may be sufficient if there is truly only one tooth that is a problem. However, the periodontal disease that causes loose and painful teeth is under the gum line, so it cannot be seen by looking in the mouth. An effective evaluation of dental health requires x-rays, which is why we have this done regularly when we go to the dentist. And if teeth are to be extracted, there should be x-rays taken before and after to evaluate the bone health and make sure no root remnants are left to cause problems. I recommend not just symptomatic removal of the tooth with the obvious problem but a thorough evaluation, including x-rays, which is likely to take longer than just a few minutes. And I don’t recommend dental work without intubating (placing a tube in the airway to control anesthesia and oxygen levels and protect the airway from blood, saliva, and other fluids and debris). As you know from your own experience, dentistry is wet and messy, and while we can protect our own windpipe durin dental treatment because we are awake, anesthetized pets cannot and so should be intubated.
Doing dentistry properly is more time-consuming and expensive than taking shortcuts, but I believe it is better for the patients.
Glad to hear it. Sorry I was out of town and didn’t get back to you in time.
Thank you. I went along with what was recommended. The next time, I will ask for x-rays.
Just had to come back and let you know, you were right. My little dog started experiencing some pain/discomfort x 3-4 days, looks like it’s one of her back molars.
Anyway, she’s in today for a full dental/x-rays/extractions as needed.
Hopefully all will go well. Hope this helps someone.
One tooth and 2-3 root remnants extracted….
You would have never known just by looking, till symptoms began and x-rays were taken.
All went well, she was in and out in a few hours. Full dental cleaning and exam done π
Is this stuff safe “fragaria vesca”?
I was trying to explain the importance of professional dental cleanings for dogs when indicated.
I was met with comments such as, my dog is too old, or my dog has medical issues (or both) and the vet is not comfortable putting him under general anesthesia.
Instead it seems that some folks are purchasing this herb(?) with the belief that it will remove tartar and clean the teeth.
Any adverse effects that you know of? I understand it won’t do the job but I can’t seem to articulate that to others π
Here is the 411 on it http://www.abchomeopathy.com/r.php/Frag-v#0
Sorry, if I am being a pest but it bothers me when people fall for this stuff :/
Thanks in advance
If this is truly a homeopathic product, then it is essentially nothing but water. No effects at all, good or bad. Unfortunately, supposedly homeopathic remedies are often improperly made and turn out to contain harmful substances, such as this homeopathic teething remedy than contained belladonna. And, of course, as you point out it is just fooling the owner into thinking they are doing something when they aren’t.
Thanks,.
I just wanted to check, is it okay if I quote you from time to time? I would always provide the link to the article and your website.
I have been doing this, but wanted to know if it was okay?
Sure, the purpose of the blog is to provide information that people find useful, so you’re welcome to cite it.
Thanks, I don’t know how much I’ll be posting on forums anymore though. The homeopathic crowd attacks me whenever I present an opposing opinion or facts.
However, I will try to help when I can.
Anyway, regarding my little dog and her teeth, she definitely has periodontal disease, despite daily brushings and the best of care.
It’s genetic, especially with small breeds, as I’m sure you know, skeptvet.
Thanks again
Ps: I do think the daily brushings helped, she just started to show symptoms recently.
I recently got into a back and forth on another forum about whether vet techs are allowed to do dental cleanings while the dog is under general anesthesia?
A vet tech tells me they are allowed to do the cleanings?
If this is true, I would prefer to go to a board certified veterinary dentist even if I have to pay more.
I brush my dogs teeth every day so they usually only need a professional cleaning once or twice per lifetime, if at all.
I will be talking to my vet. But I wanted to hear what the vets have to say.
Thanks
From a regulatory perspective, each state is different. In CA, as an example, technicians are allowed to clean and polish, chart, and take radiographs, and with supervision they can perform dental extractions and suture the extraction sites. They are prohibited from performing surgical extractions. Other states may have different rules.
From a medical perspective, routine dental treatment, such as taking radiographs and cleaning/polishing teeth, are perfectly appropriate for properly trained technicians. Most of us have our teeth cleaned by technicians, not dentists, and there is no reason this should be a problem for veterinary patients.
As for anesthesia, veterinarians are in charge of supervising anesthesia (choosing drugs, dealing with any complications, etc.), but technicians routinely administer and monitor anesthetics for most procedures, and there is no reason dentistry should be an exception to this.
Obviously, technicians should be properly trained and supervised for any task they perform, but there is no reason they cannot perform the same procedures in our patients as dental hygienists and nurse anesthetists do for humans. There is even an academy of veterinary dental technicians that coordinates specialty certification for technicians wishing to focus on dentistry as their primary area of responsibility. Such technicians can provide excellent care to veterinary dentistry patients.
When I get my dental cleanings, I am not under general anesthesia.
Thanks for your response. I am disappointed.
I am paying $$$ for a vet tech to do the cleaning . Not cool.
I have observed more than 1 vet tech make an error, I am not impressed with their skills.
I know they work hard and mean well, that’s not the point.
As a pet owner I have to pay for their errors.
the solution is to licence the person doing the dental procedure rather than just licence a person in the building when the dental is done.
Sounds good π
Years ago I had a small dog (brachycephalic) in for a routine dental cleaning.
Guess what, when I picked him up they told me his jaw broke during the cleaning, his jaw was wired and I had to hand feed him for 6 months.
No apology, and I had to pay for all the extra work.
Now I have to wonder if a vet tech was responsible?
I didn’t complain or make a fuss, in fact I still go to that clinic.
Another time, different dog, different clinic I observed a vet tech make a significant medication error.
Never went there again, because the girl was not fired.
I again did not make a fuss, I know accidents can happen.
No apology, nothing.
So forgive me for being cautious.
Thanks for listening.
Well, from a vet’s perspective, I think the reliability of technical skills i mostly associated with how often they are performed. My techs are going to be far better at drawing blood or putting in IV catheters or cleaning teeth than I am because that’s there job and they do this daily, whereas like an MD or a dentist I hardly ever perform those skills. The vet’s job is really to make medical decisions and to perform specialized, high-level skills (surgery, ultrasound, etc.). You will pay more for a vet to do these things since vet time is more expensive than tech time, and you will probably not get better care.
I understand why this would make you cautious, but I don’t think the assumption that such errors are less likely if a vet performs routine technical procedures instead of a properly trained and supervised technician. Again, that hasn’t proven to be true in human medicine, and it doesn’t seem to me likely to be true in vet med.
My small dogs receive dental cleanings under anesthesia annually or biannually depending on the condition of their teeth. There is usually an extraction or two each dental cleaning. Sometimes antibiotics are prescribed. Dental xrays are not available at my vets office. I don’t doubt the need for the teeth to be pulled. In fact, I have doubts about the benefits of xrays being worth the additional costs when measures to save teeth don’t seem to be available. Can you help me understand the full benefit of xrays if the teeth are just going to be pulled “as needed” rather than some tooth saving intervention (like a filling or crown)? If the additional cost is warranted – is this something worth changing vets over since dental xrays are not available at my current vet’s clinic?
I believe there is value to dental x-rays, and most dental specialists would argue that it is an essential part of appropriate dental treatment, just as it is for humans. There is limited research literature, of course, but the following study suggests that important lesions can be missed without x-rays:
Am J Vet Res. 1998 Jun;59(6):686-91.
Diagnostic value of full-mouth radiography in dogs.
Abstract
OBJECTIVE:
To determine the diagnostic value of full-mouth radiography in dogs.
SAMPLE POPULATION:
Prospective series of 226 dogs referred for dental treatment without previous full-mouth radiographic views being available.
PROCEDURE:
In a prospective nested case-control analysis of multiple outcomes in a hospital cohort of dogs presented for dental treatment, full-mouth radiographic views were obtained prior to oral examination and charting. After treatment, clinical and radiographic findings were compared, with reference to presenting problems, main clinical findings, additional information obtained from the radiographs, and unexpected radiographic findings. The importance of the radiographic findings in therapeutic decision-making was assessed.
RESULTS:
The main clinical findings were radiographically confirmed in all dogs. Selected presenting problems and main clinical findings yielded significantly increased odds ratios for a variety of other conditions, either expected or unexpected. Radiographs of teeth without clinical lesions yielded incidental or clinically important findings in 41.7 and 27.8% of dogs, respectively, and were considered of no clinical value in 30.5%. Radiographs of teeth with clinical lesions merely confirmed the findings in 24.3% of dogs, yielded additional or clinically essential information in 50.0 and 22.6%, respectively, and were considered of no value in 3.1%. Older dogs derived more benefit from full-mouth radiography than did younger dogs. Incidental findings were more common in larger dogs.
CLINICAL RELEVANCE:
Diagnostic yield of full-mouth radiography in new canine patients referred for dental treatment is high, and the routine use of such radiographs is justifiable.
Thank you for your reply.
I guess it depends on what “clinically important findings” means in the real world. Does that mean they pull the tooth now when they normally wouldn’t have OR that they make a note to recheck the tooth on next year’s dental? Then we need a study to determine if the dog’s quality or quantity of life is significantly improved when a tooth is pulled prior to visible symptoms vs the tooth being pulled the following year when it had deteriorated a little further. Would be nice to have my own research teams to assist me in making my veterinary care choices lol
Umm, root remnants, not visible, except by x-ray.
Left over when a tooth breaks at the root, or falls out, but not completely.
Usually due to chewing on bones, also due to periodontal disease.
Not visible without x-rays. Most of the trouble is below the gum line, not visible by a physical exam.
X-rays are important, especially if you see redness and inflammation, regardless of how good the teeth look on the surface.
he COVID 19 pandemic means I have increased time at home with my dog, who needs improved dental maintenance. She is a 7 year old husky/shepherd/mystery mix. She has had two full dentals (at 4.5 and 6 years old). Despite tooth brushing and following my vet’s recommendation of feeding seaweed and switching her to filtered water, her teeth and breath continue to decline. I purchased ProDen powder, new toothpaste, edible bones (all VOHCA accepted products). I was thinking about getting a dental dog food, but the nutritional levels seem sub-par. Should I also start a chlorhexidine rinse? The VOHCA accepted dog water additives are unavailable online. Is it worth trying something else?
Brushing is certainly the most effective approach. The evidence for many of the products on the VOHC list is limited, and no one has looked at combining products. Seaweed and filtered water are not evidence-based interventions, so I’d be skeptical of those. Ultimately, a professional cleaning will be necessary at some point, but dental disease is chronic and progresses slowly, so I think what you’re doing is reasonable, and I wouldn’t look too hard for more or something magical that’s going to make a dramatic difference.
Another great post.
How do you deal with this in very old canines?
This article is quite old, so I took a quick look for any more recent evidence. so far, there still seems to be a pretty tenuous link between pd and systemic diseases. One retrospective review from 2019 only found an association with cardiovascular disease. Since mitral valve disease and periodontal disease are both far more prevalent in small breed dogs, this could be a result of confounding, and it is not clear from the paper whether this was looked at. In any case, still plausible but unproven that dentistry improves general health, though it certainly improves oral health and quality of life for many dogs.
PD is clearly associated with age, so older dogs are more likely to experience it and to need treatment. The concern is that effective treatment requires general anesthesia, and the risk of this can be higher in older dogs. That said, healthy geriatric patients without significant specific comorbidities that preclude safe anesthesia are still good candidates for treatment. And if the degree of suffering due to the dental disease is great enough, treatment benefit may justify the risk. I have done dental work on dogs with stable congestive heart failure, and they have not only survived the procedure but been more comfortable and apparently healthier afterwards, so it can be done if case selection and anesthetic management are judicious and appropriate.