Focus on feline dental care and its effect on overall health: A roundtable discussion (Sponsored by Greenies)

Feline dental care is an often-neglected area of veterinary medicine. For cat owners, oral home care and the dental procedures recommended by their veterinarians are often a source of stress and misunderstanding. A group of veterinary professionals recently gathered to discuss why feline dental care is important to their patients' overall health, how to effectively encourage cat owners to seek regular veterinary care, and what to focus on to provide the best services possible for their clients and patients.

Dr. Karyl Hurley: Welcome everybody. Today we will be talking about feline oral health and care. Let's start with the importance of regular veterinary visits. Recent information shows that cats visit veterinarians less than dogs do. Why are people less likely to seek veterinary care for their cats?

Karyl Hurley DVM, DACVIM, DECVIM-CA, Waltham Centre for Pet Nutrition, Leicestershire, England

Dr. Margie Scherk: The two main reasons people don't take their cats to the veterinarian are, one, cats show such subtle signs of illness that owners don't recognize they are sick and, two, it is no fun to take cats to the clinic. Our challenges as veterinarians are to educate people that cats do need our help, to provide an environment that is more cat friendly, and to teach owners how to bring their cats into the clinic in a way that is less traumatic for the cats and clients. A number of feline wellness guidelines and programs are available through various organizations. The Morris Animal Foundation and the CATalyst Council are two. Healthy Cats for Life, a campaign of the American Association of Feline Practitioners (AAFP), is another. The Feline Advisory Bureau provides information, and the American Animal Hospital Association (AAHA) in conjunction with the AAFP has developed well-cat guidelines. The American Veterinary Medical Association (AVMA) website is another source of information on feline health and wellness. All of these groups suggest that cats—even healthy cats—be seen twice a year.

Margie Scherk DVM, DABVP (feline), CatsINK, Vancouver, B.C., Canada

Dr. Richard Goldstein: We are in a transition phase from the vaccination schedule driving the frequency of veterinary visits to a better way: biannual check-ups based on age and wellness.

Richard Goldstein DVM, DACVIM, DECVIM-CA, College of Veterinary Medicine, Cornell University, Ithaca, N.Y.

Debbie Boone: I'm working with several practices as a consultant, changing their protocols to focus on risk factors and wellness rather than annual vaccinations. We need to educate clients about bringing cats in for healthy cat visits. The other important factor is improving the experience for both owners and cats. Perhaps there needs to be a focus on proper handling of cats to ensure a friendlier visit.

Signs of oral pain

Hurley: Let's discuss feline oral pain. Oral pain in cats can be hard for clients to recognize. How can we educate clients to help them realize that oral pain exists and that they shouldn't ignore it?

Dr. Brook Niemiec: Cats almost never show recognizable signs of oral conditions. Yet, after various oral problems have been treated, clients see a difference in their cats' behavior because we've relieved pain that had, in fact, been present. The fact is, most animals have oral pathology of some sort.

Debbie Boone BS, CCS Principal, Debbie Boone 2 Manage Vets Consulting, Gibsonville, N.C.

Dr. Jan Bellows: The most common sign I see when cats have oral pain is that they stop grooming because it hurts, resulting in a dull, possibly matted hair coat. After we remove the problematic teeth, which we often have to do, they start grooming again. Their coats get shiny, and the cats appear much happier. The mouth is an important part of a cat's overall well-being.

Brook Niemiec DVM, DAVDC, Southern California Veterinary Dental Specialties, San Diego, Calif.

Niemiec: With eating, grooming, and other behaviors, the change is often gradual. It generally comes on so slowly that clients don't recognize it. The cat may just be less interested in interaction, which can go unnoticed. Owners of a cat with caudal stomatitis will often tell me that they brought their cat in because it stopped eating. I'll treat the cat and send it home, and two weeks later the clients will come back and tell me that their cat wants to be petted and seeks attention—something it hasn't wanted in years. That's because its mouth has been hurting for years. A decrease in seeking human interaction is a common sign of pain.

Boone: Clients often don't know how to recognize the signs of pain. In my practices, I have clients fill out a health evaluation when they walk in. By answering questions about their cats' behavior (e.g. Has your cat been hiding? Has your cat been eating well? Has your cat been drinking less?) clients learn to look for those behavior changes and may be able to recognize important changes early.

Jan Bellows DVM, DAVDC, DABVP, All Pets Dental, Weston, Fla.

Scherk: That is really important with cats. Many people think of cats as solitary and independent, but that is not actually true. Those of us who live with cats know they are "in your face" and under your feet when they are well.

Niemiec: Most clients' perception of when their pets experience oral pain is when they stop eating. But most animals will not stop eating because of their mouths; they stop eating for other reasons. Studies have revealed that between 30% and 50% of cats older than 3 years old have at least one painful tooth resorption.1-3 They are in pain and are suffering, but they will often still be eating.

Scherk: The pain may not keep them from eating, but they may drink less because of sensitivity of the exposed dentin. Because cats are predisposed to dehydration anyway, this can make many other things worse.

The oral examination

Hurley: Having convinced clients to have their cats examined, let's take some time to discuss common oral examination findings and other diagnostic tools.

Bellows: You first have to look at the common areas of tooth resorption. The tooth right behind the lower canine is most prone to resorption. In many cases, veterinarians won't see a tooth there or they will see a bump or an area of inflammation. Since any tooth can be affected, you really have to look at each one. After a good examination of the facial surfaces, open the mouth to look deep into the pharynx, and pull out the tongue a little to see if there is oropharyngeal inflammation. To look further, you'll need to place the cat under general anesthesia and perform dental radiography.

Scherk: You have to look under the tongue because so much stuff—not just string or other foreign bodies, but many lumps and bumps—can be hidden under it.

Bellows: We find that many cats with chronic oral disease will have increased serum globulin concentrations because of chronic infection. This increase is one of the findings veterinarians can see when examining a wellness blood profile once a year.

Goldstein: When a cat has an increased globulin concentration, which is the protein that reflects chronic inflammation, the first thing I ask is, "How is its mouth?" Chronic smoldering inflammation of the mouth can drive the globulin concentration up markedly.

Niemiec: Another concern is that cats frequently break their canine teeth. They only break about 1 mm off, but in cats that is often enough to expose the root canal. The root canal is about 0.5 to 1 mm away from the tip of the crown.

Bellows: As part of the oral examination, I gently press a cotton swab against each tooth-gingival facial surface. Often when we get to the mandibular third premolar, a patient's teeth will chatter because of the pain. Clients are amazed and motivated to treat to alleviate the pain.

Niemiec: I commonly see periodontal disease in cats, especially in Burmese, Siamese, and Tonkinese cats. Those breeds tend to get more severe periodontal disease in my experience.

Scherk: It is critical to understand that you cannot perform a proper oral examination on a conscious cat. Sedation is not enough; they need to be anesthetized. The teeth most commonly affected by tooth resorption in cats are the mandibular third premolars located immediately behind the canines. Often it is difficult to visualize these teeth without moving the lower lip laterally. Commonly, the only presenting sign is an oral swelling where the third premolar used to reside. Intraoral radiographs of this swollen area, as well as of the rest of the mouth, are indicated to determine if surgery needs to be performed. Without performing radiography, preferably taking eight radiographs of a cat's mouth, you will not see the true extent of the pathology.

Dental radiography and anesthesia

Niemiec: You simply cannot treat dental problems without performing radiography. Adding dental radiography to a practice's dental protocol is the best way to improve the quality of dental care.

Boone: Digital dental radiography is one of the easiest things in the world to practice and learn. Almost any healthy patient under anesthesia can be a subject (with owner permission), or you can use a skull.

Scherk: Additionally, you are not dealing with a long development time. It used to be that while you were taking eight radiographs in a cat's mouth, developing each one of them, and waiting to see which ones needed to be repeated, your anesthetized patient could become hypotensive. With digital radiography, everything can be done quickly, keeping anesthesia times short.

Lori Bollinger: Clients are concerned about anesthesia. We have a lot of new clients, so establishing trust can be difficult for us. I talk to clients about our anesthesia and pain management protocols and go over the estimates carefully. We conduct presurgical blood work, monitor appropriately, and take digital dental radiographs. Establishing trust with clients and fully informing them about what we do makes them feel better about the process.

Lori Bollinger RVT, CVDT, Camelot Court Animal Clinic, Leawood, Kan.

Bellows: To mitigate the fear of anesthesia, we explain that anesthetic procedures are safer than ever before, that we monitor anesthetized patients carefully, and that the anesthetic protocol is tailored to the individual patient. We evaluate the patient to make sure it is a good candidate for anesthesia. We perform a complete physical examination, laboratory tests, an electrocardiogram, and a urinalysis, depending on the patient's medical condition and life stage. If the patient is more than 8 years old, we will perform thoracic radiography.

Hurley: Do you recommend a complete dental examination and cleaning under anesthesia annually? And if so, at what age do you start doing this?

Bellows: The AAFP/AAHA guidelines suggest that a dental examination be done at least yearly. Now the view is that a dental cleaning should be performed whenever marked plaque and calculus are on the teeth, rubbing against the gingiva—regardless of how long it has been since the last professional cleaning. In some cases, that means every six months or sooner.

Niemiec: Plaque and calculus are signs of disease. It's the inflammation of the gums that is the disease. I've seen a lot of patients with pretty clean teeth that have horrific amounts of inflammation.

Bellows: It all starts with the kitten visit. You have to start preventive care from day one. We initially look at the mouth under anesthesia when patients get spayed or neutered. We radiograph all of their teeth. I generally start regular dental evaluations and cleanings at 1 year of age and then once a year or every six months.

Table 1: Feline Wellness and Dental Care Resources

Niemiec: If clients start brushing their pets' teeth before gingivitis and periodontal disease occur, then brushing just a couple of times a week can be sufficient. Once periodontal disease is established, clients have to brush every day.

Boone: It is important to remember that you don't have to do everything at one time. Doctors often try to save their clients money by bundling oral care with a growth removal or some other surgical procedure. This is not patient-focused care.

Goldstein: I would stress that an extended anesthesia time may be worse than anesthetizing the patient three separate times. Do procedures as needed, and if that means performing two procedures six months apart, that's fine. Obviously, we should emphasize prevention, starting when cats are young and healthy, and catching problems early.

Niemiec: Every day I hear, "My veterinarian says my cat is too old for anesthesia." I routinely anesthetize patients in their late teens and into their 20s. These patients do well as long as they are evaluated thoroughly to make sure they are in sufficient health prior to anesthesia. Old age is not a disease.

Scherk: There are quality of life issues to consider. A cat is much better off with treatment than with chronic pain. The American Society of Anesthesiologists has a wonderful staging table that I use when I'm speaking, showing that age is not a disease or a risk factor. There are two studies, one in the British Journal of Anaesthesia involving cats and one in the Journal of Veterinary Emergency and Critical Care that looked at the risk of anesthesia associated with age in cats, and there is no correlation.4,5 I would emphasize that individualized patient care is critical to a patient's well-being.

Bollinger: Technicians are now taught in school about the importance of monitoring anesthesia. We learn to not strictly pay attention to the machines, but to look at the animals, too. When I am performing a routine dental cleaning, I am focused on the mouth, so I am not looking at the whole animal. But another technician is carefully monitoring the patient the entire time. We want to make sure the patient is safe and well cared for.

Table 2: Subtle Signs of Oral Pain

Tooth resorption

Hurley: Let's now discuss tooth resorption, a common dental problem in cats. What causes tooth resorption, and how do you treat this problem?

Bellows: We know a lot of things that do not cause tooth resorption. We know it is not caused by early neutering. We know the feline leukemia or feline immunodeficiency virus does not cause it. We know it is not caused by failing to brush a cat's teeth. It may be due to nutritional issues such as calcium and vitamin D concentrations in some pet foods. Research is ongoing. Because these lesions are considered progressive, the only treatment is extraction. Watching and waiting are not going to help. You can't fill the teeth because the resorption starts inside the tooth. Placing something on top of the tooth is not going to help it at all.

Niemiec: Unfortunately, by the time we see resorptive lesions they are pretty bad. Clients ask me every day, "What can I do?" or "How can I stop these?" and I don't have an answer.

Scherk: If we don't know what causes resorption, we sure don't know how to prevent it. Tooth resorption has nothing to do with what the clients are doing or not doing. So far, we do not have the answers to these questions.

Hurley: And the only way to diagnose tooth resorption is with radiography?

Niemiec: You can see some of these lesions clinically, but radiographs are critical for diagnosis and treatment. There are three types of tooth resorption, and management depends on the type. So you don't know how to treat them unless you have a radiograph. You simply can't practice dentistry without dental radiography.

Bellows: Determining type is a radiographic diagnosis. All of the classifications are on the American Veterinary Dental College (AVDC) website, AVDC.org. OralATP.com is another good resource. With type 1 disease, the tooth still has a normal opacity. Type 1 disease probably has more to do with periodontal disease than it does with tooth resorption. Treatment of teeth affected by type 1 disease includes extraction of the crown and roots. Type 2 disease signifies bone remodeling. The tooth root is resorbing, being replaced with bone-like substance. Unfortunately, because the oral cavity is exposed to these lesions originating underneath the gum line in type 2, you have to remove the crown to a level underneath the gingiva and then suture the gingiva. This does not apply in cases of stomatitis, just with individual tooth resorption. Type 3 disease has a little of both. Sometimes one root is resorbing and one root has periodontal disease. In that case, you have to extract the whole tooth.

Table 3: Types of Resorption, Based on Radiographic Appearance

Stomatitis and systemic effects of dental disease

Hurley: Let's discuss another oral problem of cats—stomatitis. Would you begin, Dr. Bellows?

Bellows: Stomatitis is thought to be a hyperimmune response to plaque and to the different pathogens in plaque. That is why some cats still have lesions in the caudal pharynx even after we remove all of their teeth. There is plaque on the barbs of the cat's tongue all the way to the back. Stomatitis is diagnosed based on a persistent inflammation of the mucous membranes of the mouth. Mucositis is the term we are now using rather than stomatitis. Stomatitis is severe inflammation throughout the entire mouth. Mucositis is inflammation around the gingival surfaces that is not classified as gingivitis or periodontitis. The general treatment is to try to control plaque in those areas. In my practice, in minor cases we rub the cat's mouth with a cotton-tipped applicator to remove the plaque every day. If the inflammation persists or gets worse, then the teeth are removed in that area.

Scherk: Stomatitis is multifactorial and multietiological, and there may also be a dietary component. Calicivirus infection plays a role in it as well, which may be why a full mouth extraction results in marked resolution of the inflammation in some cats, but in others it does not.

Bellows: In some cases, the lesions clear up when you change a cat's diet in addition to extracting resorbing teeth and those that have periodontal disease. We have tried a novel-protein diet. It is not a first-line treatment, but anecdotally the lesions resolve in some of the more persistent cases. The one thing that should not be given is corticosteroids. Not only will you have a cat with a raw mouth as soon as the steroids wear off, the cat may become prediabetic or diabetic. Some cats with stomatitis also have inflammatory bowel disease. They have oral lesions and intestinal lesions.

Hurley: When you have a source of inflammation in the mouth, it may lead to systemic inflammatory disorders.

Goldstein: Right, and the converse is true as well. We know that cats may be even more susceptible than dogs are to the effects of systemic inflammation. Having a source of inflammation in the mouth may lead to inflammation in the gut, pancreas, liver, and in all other organs. Another characteristic of cats, which is relatively unique, is their susceptibility to type 2 diabetes. Whenever cats secrete insulin, they secrete a protein, amylin, which damages the pancreas. The more we demand that cats secrete insulin, for instance in a case where insulin resistance is induced by systemic or oral inflammation, the more they damage their pancreases. Any chronic source of inflammation would predispose cats to diabetes, in addition to the more classic inflammatory lesions.

Then, of course, there is the kitten. Fifty percent of cats have tooth resorption by the age of 3, and up to 35% of older cats have chronic kidney disease.6 We don't know what the inciting cause of chronic kidney disease is in domestic cats, but it makes a lot of sense that it would correlate to a chronic source of inflammation. Then there is the fact that cats are always on the verge of dehydration. Anything that decreases their water intake can affect their kidneys.

Hurley: Some animals have been administered antibiotics before dental cleaning to prevent hematogenous spread of bacteria. Is that a common practice today?

Bellows: The pendulum has definitely swung the other way, to the point that most veterinary dentists are not administering any antibiotics. You extract the problematic teeth, and the gums heal gorgeously. These are healthy patients, not those with mitral insufficiency, cardiac failure, or kidney failure, or animals with bone implants. These are the patients that just have a mouth that needs to be cleaned. I've been practicing for 35 years, and we used to administer a penicillin injection before cleanings, but we don't do it at all now.

Goldstein: Concurrent diseases are a reason to deal with the mouth, not a reason not to.

Niemiec: If a cat has periodontal disease, it is showering itself with bacteria every day. A dental cleaning is only mildly more bacteremia-producing than daily mastication, therefore antibiotics for routine assessment, treatment, and prevention are not always indicated.

Hurley: What about patients with cardiac disease or that are retrovirus positive?

Bellows: Yes, we give them antibiotics. We usually administer clindamycin that day because it gets into the serum within 20 minutes. We generally recommend administering antimicrobials for a week after surgery.

Local effects of dental disease

Hurley: Now let's discuss some of the more localized problems associated with dental disease.

Niemiec: We should mention the oronasal fistulas, jaw fractures, eye loss, abscesses, and all the other disorders that can occur locally in cats with chronic dental disease.

Scherk: I certainly see fistulas, retrobulbar abscesses, and osteomyelitis.

Niemiec: I have seen numerous cases of eye problems secondary to abscessed teeth and severe periodontal disease, and oronasal fistulas are relatively common.

Bellows: I also think many cases of sinusitis are caused by chronic dental disease.

Niemiec: I've seen a few cats that have had enucleations because of chronic periodontal disease. In most cats, the roots of the upper fourth premolar and canines are located right below the globe. If a cat has a chronic infection there, it is going to affect that eye, and the cat may lose the eye over time.

Dental home care

Hurley: So to help prevent some of these consequences of chronic dental disease, what oral care do you routinely recommend to cat owners?

Niemiec: I like tooth brushing, and if it is started when a cat is young and is done well, it can be effective. Owners should start with a toothbrush dipped in tuna juice and go slowly, making it a positive experience. Every puppy and kitten should go home with a toothbrush and toothpaste. I prefer a small child's or an infant's toothbrush.

Bellows: A cotton-tipped applicator works OK, and a gauze sponge works phenomenally. Clients don't have to put anything on it. They just place it around a finger and rub the surface of the maxillary fourth premolars on both sides.

During a dental procedure, we apply ORAVET BARRIER SEALANT (Merial). Afterward, we encourage clients to place a bit of ORAVET PLAQUE PREVENTION GEL on the end of their fingers and rub it on the surface of the premolars. ORAVET creates a barrier between the teeth and the bacteria that would love to inhabit them. The gel stays on for nearly a week.

Niemiec: Chlorhexidine is also great against plaque. If clients brush their cats' teeth with chlorhexidine, it makes a world of difference. If they can't brush with it, they can use a small amount of it as a rinse or on gauze—anything to get it in there. Once it is absorbed by the oral mucosa, it exerts antibacterial effects for up to six hours because it is impregnated within the oral structures.

The other product I like is MAXI/GUARD ORAZN (Addison Biological Laboratory). It is a zinc-based product that supports collagen synthesis, and it is antibacterial and tasteless. It has been clinically proven to decrease gingivitis in cats. I rub a small amount onto the gums.

Bellows: I find it is helpful to invite clients back to the practice once a month to see how they are doing with the home care, and we do that at no charge. It lets them know someone is concerned and available to answer questions. But if they ask, "Can you take a look at that lump?" I tell them I'll have a technician come in and get a history. She lets them know it is not a free examination.

Treats and diets for dental health

Hurley: Since compliance is an issue with tooth brushing, do clients tend to rely on diets and treats for home dental care?

Niemiec: It has been shown that feeding standard dry kibble vs. wet food has minimal effect on gum disease.7 There are dental diets, some of which have been proven to work and some of which have not.

Bellows: The Veterinary Oral Health Council (VOHC) is a nonprofit organization that is part of the AVDC. It is set up to evaluate dental products' effectiveness at controlling plaque or calculus. Approved products get a Seal of Acceptance, which is similar to the Good Housekeeping Seal or the American Dental Association Seal of Acceptance. VOHC-approved products are great.

Boone: With any of these products, we are prolonging the time between professional oral care visits. Clients' concerns about finances or anesthesia are major selling points for using dental treats and specialized diets.

Bollinger: Our clients are definitely compliant with FELINE GREENIES® dental treats. They go over very well.

Niemiec: Tooth brushing is the gold standard, but if it isn't done, then passive home care, such as using diets and treats, is a good idea. If a client gives a cat a chew-based treat such as FELINE GREENIES® dental treats or any of the proven dental diets, the product is only effective where the cat chews. The treat is not going to affect the canines or incisors. And when clients brush their pets' teeth, they are usually fairly effective on the canines and incisors but cannot get to the back of the mouth. So a combination of the two is probably best.

Hurley: AAHA has guidelines on dental health. Do they recommend treats?

Bellows: Yes, AAHA recommends VOHC-approved products.

Client communication and educational tools

Hurley: What visual or other educational aids do you use in practice to communicate with your clients about dental disease?

Bellows: In our practice, we have a card in our digital camera that allows us to broadcast wirelessly to our computer. We take a picture with the camera, and it appears on the computer screen. We give a copy of the photo to the client.

Bollinger: We take digital radiographs and give clients copies. It gives them more confidence in us when they can see what the problem looked like and what we did to fix it. A picture speaks a thousand words.

Niemiec: We actually bring clients into the operating room to show them the oral pathology while their pets are anesthetized as well as go over their pets' dental radiographs before we do anything.

Boone: Client education software programs also are available, which can be loaded into your examination room computers—DIA (Diagnostic Imaging Atlas—Webster Veterinary) is one program. With these programs, you can show dental images to a client and say, "Here is why you need to brush your pet's teeth. Here is why you need to provide FELINE GREENIES® dental treats. Here is what happens if you don't." It's a great show-and-tell tool.

Bellows: As veterinary professionals, we need to be advocates for our patients. This is a real disease. This is real inflammation. This hurts, and we have to do something about it.

Boone: Some veterinarians are afraid to draw a line in the sand. But the truth of the matter is we shouldn't let our clients practice medicine. We need to confidently say to our clients, "In my experience, this is what your pet needs." If they really cannot afford it, come up with a plan B. Help them out, but don't back down on patient care.

Scherk: It keeps coming back to education: client education, staff education, and doctor education. There are no shortcuts. You can't just hand somebody a brochure. You have to spend time educating.

Boone: Bringing clients back a week after a dental procedure and talking to them about oral care is important. Once their cats are feeling better, clients are much more receptive to learning about home care. You can't do "show and tell" tooth brushing on a cat with a sore mouth, but a week later the clients can usually see a noticeable improvement. This is the opportunity for the practice team to reinforce the wisdom of the client's decision to have had an oral care procedure for his or her pet.

REFERENCES

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2. Pettersson A, Mannerfelt T. Prevalence of dental resorptive lesions in Swedish cats. J Vet Dent 2003;Sept: 20(3):140-142.

3. Ingham KE, Gorrel C, Blackburn J, Farnsworth W. Prevalence of odontoclastic resorptive lesions in a population of clinically healthy cats. J Small Anim Pract 2001;Sept;42(9):439-443.

4. Brodbelt DC, Pfeiffer DU, Young LE, et al. Risk factors for anaesthetic-related death in cats: results from the confidential enquiry into perioperative small animal fatalities (CEPSAF). Br J Anaesth published online on Sept 19, 2007.

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6. Brown SC. In: Consultations in Feline Internal Medicine. Vol. 6, August JR (ed). Saunders Elsevier, China, 2010.

7. Harvey CE, Shofer FS, Laster L. Correlation of diet, other chewing activities, and periodontal disease in North American client-owned dogs. J Vet Dent 1996;13:101-105.