The science behind dental products (Proceedings)

Oral disease is one of the most prevalent diseases in dogs and cats. 80% of adult dogs and 70% of adult cats have some form of oral disease. Dental problems are among the top three pet owners concerns in dogs and cats. Calculus and gingivitis are the most common conditions diagnosed by veterinarians in all ages of animals.

Successful treatment of periodontal disease requires a multi-modal approach including thorough professional examination and periodontal therapy and the recommendation and application of an effective home care plan. Over the years, many products have been developed and marketed for dental care in pets. The range of claims and research evidence of those claims is highly variable making the decision for the pet owners difficult. The objective of this presentation is to assist technicians understand the emerging concept in decision making, termed home-based medicine and to apply this concept in a review of the evidence supporting various home care products for prevention and or treatment of periodontal disease in companion animals.

Companion animals have become an important part of our lives. Many people consider the pet a part of their family. The veterinarian and his staff must educate the client about the need for professional dental care and quality home and then convince them of its importance. Statistics show that 25 percent of your clients will accept whatever you say immediately; another 60 percent will take a little time to accept your recommendations; the remaining 15 percent will not accept your suggestions.

The Importance of Dental Home Care

As veterinary health professionals, it is our job not only to promote dentistry but to educate our clients about the importance of good oral health. How can we do this?

Oral health is achieved through a combination of professional therapy and home care. Dental home care refers to the procedures pet owners use at home to control dental substrates. The goal of dental home care is daily plaque removal designed to maintain oral hygiene and prevent the development of gingivitis and periodontal disease.

Home care does not routinely remove existing calculus and although there may be some benefit of plaque control in pets with existing periodontal disease, the best results are obtained following the appropriate examinations and therapy. Dental home care is not a substitute for regular professional examinations and treatment. Recommendation of the appropriate home care product and application is the responsibility of the veterinarian after assessment of the pet's oral pathology and the pet owner compliance through the appropriate education and training provided to the owner. Application of home care is the responsibility of the pet owner and early evaluation by the veterinarian of the effectiveness of the home care application is critical to the long-term success of the home care products. The home care method may be revised periodically revised to achieve the optimal results.

Evaluate

Before you prescribe home care for a patient, it is important to assess the client and the animal. Is the owner ready, willing and able to perform proper home care? Are they committed, interested and physically able to provide care? Does the pet have the temperament to allow for home care? All of these aspects must be considered before prescribing any home care regime. It will not work to prescribe routine brushing if you know the client will not follow through. If this is the case, you may be better off recommending an oral care diet as opposed to brushing.

Another consideration that needs to be taken into consideration when recommending home care is the degree of treatment necessary. For young pets, the prevention of plaque accumulation can be achieved by plaque removal at least two times per week. For moderate accumulations and disease, following a professional dental prophylaxis plaque removal every other day can help improve oral health. When the degree of disease is severe, professional periodontal prophylaxis is necessary followed by twice a day chlorhexidine rinses for one week and then once a week chlorhexidine rinses and daily brushing.

Demonstrate

Demonstrate oral cleansing techniques to the client. Telling a client to brush their pet's teeth without a demonstration is of no benefit. When demonstrating, use a soft bristled brush or gauze. Use a 45 degree angle to the tooth and circular motion. It is important to start the demonstration on a dental model. This allows the client to see the actual brushing technique without the lips getting in the way. The model also shows them what all of the teeth look like and where problem areas might be lurking. Following the model, demonstrate on the owner's pet or a clinic pet. Demonstrate on one side and observe the client brushing the other side. By doing this, you are able to evaluate their techniques and offer suggestions and tips. If you use the owner's pet, you are also able to access the pet's temperament and acceptance of the tooth brushing.

A disclosing solution can be used to help demonstrate plaque on the teeth. This product comes in individual tubes with an applicator swab that allows the plaque on tooth to be disclosed without staining the fur.

Not every client or patient is a candidate for tooth brushing. There are alternative methods of plaque control and removal. Work with your clients to determine which would be the best option for them and their pet.

Evidence-Based Medicine (EBM)

EBM has been defined as the integration of the best research evidence with clinical expertise and patient values. Best research evidence means clinically relevant research, especially from patient-centered clinical studies. Clinical expertise refers to the ability to use clinical skills and past experience to rapidly identify each patient's unique health state, establish a diagnosis, and determine the risks and benefits of potential interventions for that specific patient. Evidence-based veterinary dentistry can be simply defined as the ue of current best evidence in making clinical decisions about dental care. The following classification scheme has been propsed for the veterinary clinical nutrition and may be useful for establishing rules or dimensions of evidence for recommendations regarding veterinary dentistry. These guidelines categorize the quality of evidence into the following grades:

     • Grade I – properly designed, randomized, controlled studies in done in target species

     • Grade II - properly designed, randomized, controlled studies in done in target species in a laboratory study

     • Grade III - appropriately controlled & designed studies, nonrandomized, using acceptable models of disease or simulations in targeted species

     • Grade IV - studies in other species, reports from experts committees, case reports, opinions based on clinical experience

Grade 1 is the evidence with the highest quality for application in the clinical environment, whereas Grade IV would be evidence of the lowest quality. Grade I and II evidence is the most reliable predictor of results likely to be seen in clinical practice. Grade II studies are frequently performed for therapy and prevention of periodontal disease because dental substrate accumulations and gingivitis occur naturally in research colony animals and multiple, randomized, controlled clinical studies can be conducted easily and economically in this setting. When evaluating the strength and quality of evidence used in making clinical decisions, the distinction between efficacy and effectiveness must also be considered. Efficacy is defined as the ability of an intervention to achieve the desired results under ideal conditions. This may apply to veterinary dental studies conducted in research colony animals of a species. Effectiveness is defined as the ability of an intervention to achieve the desired results under usual conditions; e.g. home environment for dental preventive care. In general, clinical studies in the home environment would be more likely to measure clinical effectiveness than clinical efficacy.

Applying Evidence-Based Veterinary Dentistry Concepts to Home Care Decisions

The concepts of evidence-based medicine can be readily applied to veterinary dentistry. There are multiple professional and over the counter products available for dental home care. This presentation will apply the evidence-based concept to a review of several products including dental treats, foods, mechanical and chemical applications, chewing devices and pharmaceuticals.

Advise and Recommend

It is necessary to warn the client that an animals failure to improve with tooth brushing may be due to an underlying disease such as; diabetes, kidney disease, FIV or leukemia. As veterinary professionals it is our duty to also warn the client about label claims. Not all products that say "veterinarian recommended" are good for their pets. Always recommend products with solid research to back those claims. Ask for the research results to prove the product will be efficacious.

Veterinary Oral Health Council (VOHC)

In 1997, a group of Veterinary Dental Health specialists formed a group called the Veterinary Oral Health Council (VOHC). This council was formed to provide an independent means of recognizing products that meet a pre-set standard of effectiveness in retarding formation of dental plaque and/or calculus (tartar). The VOHCl rewards products that claim to provide some type of oral benefit a seal of approval. This seal of approval was based on the American Dental Seal of Approval currently use for human products. At this time, the following products have been awarded this seal.

These are the products that currently have the VOHC seal of approval.

Prescription Diet Canine t/d – Original and Small Bites

Prescription Diet Feline t/d

Friskies Feline Dental Diet

New and Improved Prescription Diet Feline t/d

Del Monte Tartar Check Dog Biscuit: Small and Large Size

Friskies Cheweez Beefhide Treats

Science Diet Oral Care Diet for Dogs

Science Diet Oral Care Diet for Cats

Iams Chunk Dental Defense Diet for Dogs

Eukanuba Adult Maintenance Diet for Dogs

Greenies Edible Dog Treats: Teenie, Petite, Regular, Large & Jumbo

Hartz Flavor Infused Oral Chews: Large and Small

Nestle Purina PetCare PVD (Dental Health) Feline

Nestle Purina PetCare PVD (Dental Health) Canine – Small Bites & Regular

Healthymouth Antiplaque Water Additive

The companies that have applied for this seal have tested their products using very strict protocols developed by the VOHC. Products that have this seal have good science behind them and have proven that they work. Additional information can be found at www.vohc.org. Look for it!!!!

Remember it is our responsibility to evaluate, educate, demonstrate, recommend and advise our clients in regards to oral home care.

References

Roudebush, P, Logan,E., Hale, FA; Evidence-Based Veterinary Dentistry: A Systematic Review of Homecare for Prevention of Periodontal Disease in Dogs and Cats. J Vet Dent 22(1); 6-15, 2005