Practical Relevance

Dental disease is the most common oral problem in dogs and catsand a major reason for them to be presented at veterinary clinics. A study in dogs showed 75% presenting with dental disease and in cats a recent study showed 67% suffering from accumulation of tartar.Such high numbers of dogs and cats affected means that advisingclients on oral health problems, their management, and prevention is a crucial role of the veterinary nurse in a busy small animal clinic.

The issue

When describing disease of the teeth the term periodontal disease is used. It is a collective term for inflammatory conditions affecting the supporting tissues of the teeth and includes both gingivitis (inflammation of the gingiva: the part of the gum that surrounds the tooth) and periodontitis (inflammation of the supporting structures of the tooth). Progressive damage to these supporting structures of the teeth can result in pain, and ultimately, tooth loss.

Plaque, tartar and periodontal disease

The initial step in the progression towards periodontal disease is the formation and accumulation of plaque on the tooth surface. Plaque forms very quickly in animals, typically within hours of any teeth cleaning. If the plaque is left to accumulate the bacteria can start to cause damage to the gum and gingivitis develops. However, if plaque continues to accumulate the inflammation starts to spread down the side of the tooth to involve the supporting structures, this is periodontitis and the animal is now suffering from periodontal disease.

Plaque that is not removed can eventually be converted to dental tartar (calculus). Formation of tartar from plaque occurs when mineral salts in the saliva precipitate out and are deposited in the plaque. As tartar continues to accumulate and extend around the tooth, the rough surface irritates the gingiva, causing inflammation of the soft tissues. Once formed, tartar is indicative of the need for dental hygiene and can only be adequately removed by professional dental prophylaxis (descaling).

Many studies on periodontal disease have documented a strong correlation between increased age and increased prevalence of dental disease. A prevalence ranging from 66% to over 80% in dogs older than 6 years of age has been noted. Periodontal disease was also demonstrated to increase significantly with increasing age and decreasing body weight resulting in a markedly greater incidence of disease in the aging toy breed dog.

Nursing advice on dental care is therefore very important for the old (senior) dog and cat as well as the smaller toy dogs (<10kg)

Dental disease and its effects on systemic disease

Dental disease is more common and often more severe in older animals who may also have compromised immune systems and other underlying diseases of the heart, lungs or kidneys. Microscopic changes have been seen in the heart, kidney and liver tissues probably due to spread of diseased materials from the oral cavity to the various organs via the blood stream.

Oral health care strategies

People agree that the best oral health care strategy is prevention. As plaque is the main cause of periodontal disease the main goal is to limit plaque accumulation and to remove already formed plaque and tartar. Regular professional dental prophylaxis (descaling and polishing) combined with consistent home care (tooth brushing) is the key to healthy teeth and gums.

The role of the veterinary nurse in oral health advice and management

The above explanation shows quite clearly that oral disease is both prevalent and potentially harmful to the animal's well being. Oral health care strategies involving the veterinary nurse must be aimed at assisting/performing dental descaling and polishing, and importantly giving advice on prophylaxis to promote oral health throughout the life of the dog or cat.

Puppies and kittens

This is the first opportunity the nurse has to talk with clients about various steps that can be taken to help promote oral health. Many practices promote puppy parties (when fully vaccinated) to help facilitate their socialization with other dogs. Talking to owners of puppies and kittens is an ideal time to emphasize oral health issues.

 Tooth brushing: Puppy and kitten owners can be shown how to brush the teeth of their new pet.This not only gets the owner use to the technique but more importantly it also gets the pet use to the procedure at an early age. Cats are usually more difficult to accept teeth brushing but with patience most will accept some degree of homecare.

 Retained deciduous teeth: these can cause abnormalities if the deciduous (milk teeth) are retained. A knowledge of normal canine and feline dentition and teeth eruption times (both permanent and deciduous) will allow the veterinary nurse to examine young animals to asses if tooth eruption is correct. Occasionally extra teeth (supernumery) appear and represent a potential problem. The opposite can also happen in that some permanent teeth do not erupt. Again a good knowledge of the normal dentition will allow correct assessment.

 Correct occlusion of the dentition and jaw: young animals can be checked to see that the teeth are correctly aligned between the upper and lower jaw and that they sit correctly when the mouth is shut. Also the jaw development can be checked to make sure that it is not under- or over-shot (the lower jaw [mandible] can be too short, or too long, compared to the upper jaw [maxilla])

 Evidence of poor oral health: although severe problems in young animals is not common the owners can be taught to look out for signs of poor oral health and how to examine the teeth in a simple way. In young animals with permanent dentition (erupted by 3.5 to 6.5 months) the owners can see what healthy teeth and gums look like. Evidence of poor oral health: bad breath (halitosis), gingivitis (+/- bleeding), accumulation of tartar, pain on eating, drooling saliva (may be tinged with blood), chipped/broken teeth (dogs that chew stones), eating from only one side of the mouth. Swelling seen on the skin around the cheek area may indicate a tooth root abscess.

Any abnormalities detected should be discussed with the veterinarian for further assessment of management options.

Nursing support during dentistry procedures

The veterinary nurse plays another central role in any dentistry procedures, from the (1) pre-operative, (2) intra-operative through to (3) post-operative stage.

Pre-operatively

 Routine preparation of the patient for a general anesthesia may need some changes especially if the animal is old and has a compromised heart, kidney or liver function. This can necessitate setting up of monitoring systems: i.e., ECG (heart), pulse oximeters (oxygen saturation). Ensuring all the necessary equipment are laid out ready for use (i.e., Dental Scalers, extraction instruments)

 Certain breeds can have a limited space at the back of their mouth (Brachycephalic breeds: boxers, pugs, Pekingese) and any potential problems need to be recognized at this pre-operative stage

Intra-operatively

 During manipulation of the head for radiographs, or tooth extraction, may lead to kinking (blocking) of the endotracheal tube (breathing tube), so a clear airway needs to be maintained

 If the throat (pharynx) has been packed for greater airway security then the packing needs to be removed before the endotracheal tube is taken out. Debris, even with hand scaling, can potentially enter the trachea [airway] if there is too much space around the endotracheal tube. Special dental packs are available with packing materials, alternatively a length of damp gauze can also be used and it should have a long free end coming out of the mouth so that it is not left behind at the end of the procedure

 In some countries veterinary nurses are allowed to perform descaling and polishing but not tooth extractions (a veterinarian has to always be monitoring the anesthesia).

 During anesthesia full evaluation of the teeth and oral cavity can be done. Special dental charts are used to record many different changes to the teeth and gums. Additionally, as the oral cavity is a site where certain cancers (tumors) can appear then any abnormal masses (lumps) on the gums, or affecting the tonsils at the back of the mouth, should be noted and the veterinarian made aware.

Post-operatively

 Before the endotracheal tube is removed the pharyngeal area should be cleared of any debris, blood clots, or fluids. Dogs and cats cannot spit out so they will always swallow whatever is in their mouth

 Dogs like the boxer, pug and Pekingese may need extra attention when the endotracheal tube is take out due to restricted space at the back of the mouth and more careful observation is needed (for example: make sure the tongue is pulled forward)

 Providing warmth (heating pads or hot water bottles: carefully positioned to avoiding any risk of burning), and continuous observation are some of the key aspects of nursing the dental patient. Pain relief will be provided by the veterinarian but the nurse can give valuable feedback to how the patient is recovering.

 Patients recovering from dentistry may try to rub their face and potentially cause damage to any procedures that have been performed. The fitting of an Elizabethan collar will help reduce any risk of damage.

 If extensive oral surgery has been performed then a feeding tube may have been placed (naso-esophageal) to facilitate post-operative nutrition. Special diets are available that can be passed down these tubes.

 If there has been extractions the gum may be very tender. Canned food can be made softer by using a fork to break it down into smaller pieces. If dry food is preferred then this can be soaked to make it soft. Liquidizing the food is not necessary. Feeding this way can be done for 4-5 days and then the animal returned slowly to its normal feeding routine.

Further advice to the clients

The importance of long-term continuous oral care should be discussed with the clients. This can be done when the dog or cat reaches adulthood, or after a dental procedure has been carried out. Support tools such as visual aids, dental models can help demonstrate what to look out for. Creating a Dental Awareness week/month in the clinic towards oral health will focus the whole staff, nurses, veterinarians and receptionists to discussing the issue with clients.

It is however recognized that owner compliance to a daily brushing schedule is questionable despite being shown what to do. Therefore additional ways for helping maintain oral health are needed.

Dental chews

Giving specially designed dental chews along with the animals normal diet has been shown to decrease tartar, plaque, and the incidence and severity of gingivitis in dogs after three or four weeks.In cats, daily access to a dental chew has also shown a significant reduction in plaque and tartar.

Nutritional advice

The standard dietary strategy involves using mechanical scraping action to clean the teeth. This has primarily been achieved by changing the texture (increasing the fiber content) and increasing the size of the kibble (pellet). These changes are claimed to increase and prolong the chewing action by the pet allowing plaque and tartar to be scraped off the surface of the teeth. A study in dogs has shown a 32% reduction in tartar accumulation after 21 days when feeding one of these diets.

Another dietary approach to the prevention of tartar is to utilize nutritional mineral sources in a way such that they can provide dental benefits. Nutritional sources of minerals can enhance the external physical properties of the kibble by creating a micro-crystalline coating. These micro-crystals do not alter the formula, or kibble (pellet) size. The minerals become incorporated in dental plaque and help prevent the conversion of plaque into tartar. These minerals are then normally metabolized by the animal. The effect of this type of diet on tartar accumulation in dogs gives an average 55% reduction in tartar formation and in cats an average of 45% reduction of tartar formation. This technique of utilizing mineral crystals is referred to as the DentalCare System. Such a system is not dependent on the chewing activity of the dog or cat, all adult life-stages are covered, including the senior animal, and it will work beyond mealtime after the animal has stopped eating.

Summary

The role of the nurse in providing practical support to promote oral health in dogs and cats is very important. It should start right at the beginning with puppies and kittens and extend throughout their lives including their senior years. The nurse plays a valuable and crucial role in helping advise clients on preventative measures and other means to promote oral health care: advice is based on

1.  Regular tooth brushing with plaque retardant substances

2.  Regular examination of the oral cavity by the owner

3.  Regular checks by the veterinarian

4.  Provision of chews to help maintain oral health

5.  Provision of food to help maintain oral health