ABSTRACT: Oral conditions and dental disease are major problems affecting cats. Periodontal disease is by far the most common of these dental diseases, and if an oral hygiene programme can be started from a young age, the need for dental treatment can be reduced Not all cats are amenable to tooth brushing and. egually, not all owners are capable of handling their cat or performing tooth brushing, resulting in very low compliance. Many products are available but are never as effective as tooth brushing. This article discusses the rationale behind tooth brushing and the next best options available, reference guide for the practice file.

Introduction

Some studies estimate that as many as 80 per cent of older cats have dental disease that needs professional treatment. Unfortunately, very few of these patients show obvious signs of oral discomfort or even any signs of disease, so the mouth often gets overlooked as a potential problem area.

Periodontal disease is by far the most common of these dental diseases and if an oral hygiene programme can be instituted from a young age, the need for dental treatment can be reduced (Figure 1).

Figure 1: Severe periodontal disease in a cat on the canine as well as a heavy build-up of showing marked gingivitis, gingival recession calculus and plaque on the tooth surfaces

Not all cats are amenable to tooth brushing and equally not all owners are capable of handling their cat or performing tooth brushing. This inevitably results in very low compliance. As veterinary professionals, we need to have a good understanding of the full spectrum of alternative products available when tooth brushing cannot be performed.

Although periodontal disease is thought of as a problem in the older cat, it will often occur in young patients too, in a much more aggressive form. Certain breeds, for example Main Coons and oriental breeds, are particularly prone to developing this aggressive periodontitis at an early age.

Periodontitis

Periodontal disease is the progressive inflammation and destruction of the periodontal tissues (the supporting structures of the tooth that hold the tooth in its socket) that eventually leads to attachment loss and, ultimately, tooth loss. The initial inflammation results from plaque accumulation on the surface of the tooth. Plaque can be described as a microbial community embedded in a matrix of polymers of bacterial and salivary origin.

The first stage of the disease occurs when the gingiva becomes inflamed, and is referred to as gingivitis. In the early stage, gingivitis is completely reversible if the plaque is removed, but if left untreated may progress to periodontitis. The tissue destruction that occurs in patients with periodontitis is partly a result of the bacterial activity, but mainly a consequence of the host’s inflammatory and immune response.

Once the tissue has been destroyed, which is seen clinically as gum recession, root exposure or even loose teeth, the destruction is irreversible and no treatment is ever going to restore the tissues and tooth back to health (Figure 2). Ultimately the tooth is lost through loss of the attachment apparatus, but the consequences of this focus of infection and inflammation are often underestimated and much more serious.

Figure 2: Periodontal probe showing furcation exposure on the mandibular 4th premolar The probe can be passed horizontally between the roots of the tooth, indicating bone loss This is irreversible

Studies have shown that advanced periodontal disease can lead to heart, liver, kidney and respiratory problems because of the bacteraemia resulting from severe periodontal disease. Periodontitis can also complicate management of diseases such as diabetes mellitus because of the chronic infection and the chronic inflammatory response; but also because of localised pain and sometimes the cat becomes reluctant to eat, making glucose stabilisation very difficult. It is always very important for nurses to include an examination of the oral cavity in diabetic patients, especially if they are inappetent.

Understanding periodontal disease, the causes and potential risk factors may help in its management. It is also important to understand that periodontal disease is not just a disease of the mouth but a disease that will have systemic consequences. It should not be glossed over as just unpleasant ‘smelly’ breath.

The only way to prevent or reduce the risks of periodontitis is to remove plaque on a daily basis. Daily tooth brushing is the best way to control plaque accumulation; however, this is not always easy or practical in cats.

Compliance studies in cats with tooth brushing have only been conducted by one leading food company and results showed that after six months, owners had completely stopped tooth brushing. This, however, should still be recommended as the gold standard, but the client should be instructed on how to brush with frequent check-ups.

Tooth brushing tips for cats

The owner should be shown how to begin tooth brushing. Many owners introduce brushing too quickly and the animal, young or old, then becomes distressed. Tooth brushing needs to be introduced in a pleasant way. Always use a medium-bristled toothbrush of suitable size. A normal adult tooth brush works well in cats as all teeth in a quadrant can then be brushed at the same time.

If toothpaste is used, it is essential that it is a pet toothpaste that does not contain fluoride as pets will swallow the toothpaste and excessive ingestion of fluoride can lead to toxicosis.

•   Check the mouth to ensure that there are no painful areas – resorptive lesions occur at the gingival margin and will be very sensitive if brushed. Never recommend tooth brushing without examining the cats mouth first.

•   Many owners struggle just holding their cats head still – the head should be held firmly with a thumb and forefinger of the non-brushing hand over the zygomatic arch on either side and the lip gently pulled back with the thumb. At the same time the head is just tilted slightly (Figure 3).

Figure 3: Head held firmly, and tilted, allowing access for tooth brushing

•   Use toothpaste on a finger or cotton- bud and gently apply under the lip onto the outer surface of the canine tooth so that the cat becomes used to it.

•   Cotton buds are a good way of getting the cat used to a foreign object in the mouth and often easier than a finger, with a reduced risk of being bitten.

•   Initially aim to clean all the buccal (outer) surfaces of the teeth but then progress to cleaning the palatal and lingual (inner) surfaces – this is not always possible in cats, in contrast to d
ogs.

•   Warn the owners that there may be some bleeding from the gingiva but explain this is normal initially and should reduce within the first five days. This bleeding is not painful and usually indicates that there are areas of gingivitis in the mouth. If the bleeding does not subside, then the cat should be seen for a dental check.

Mouth washing

Given the low compliance rate in owners brushing cats’ teeth, other measures are often sought. The chlorhexidine mouth washes and gels are an excellent second best.

Chlorhexidine is a synthetic cationic bisbiguanide antimicrobial agent which is the most effective chemical agent available for the prevention and reduction of plaque accumulation and gingivitis. It has a broad spectrum of activity. The main advantage of chlorhexidine is that it not only binds to the pellicle reducing further accumulation of plaque on the tooth surface, but also eliminates existing plaque.

It has an ability to bind to the oral tissues, as well as the teeth, and some studies have shown that it remains active for up to 12 hours following application. Most other oral antiseptics are washed away by saliva. The concentration that should be used is 0.12% to achieve these best results.

The mouthwashes can be used by applying them to the toothbrush instead of a toothpaste or on cotton buds to rub along the gum margin. They can also be used by syringing into the mouth although this is not as effective as application directly on to the tooth surface.

A chlorhexidine gel can be applied directly on to the tooth surface with a finger if the cat allows. The products I recommend are Hexarinse (Virbac) and Pet dent Oral gel (Kyron Laboratories) – both are available through most veterinary wholesalers.

Other products are available that do contain chlorhexidine but they are either at too low a concentration for the chlorhexidine to be effective or are in a formulation where the chlorhexidine may not be released or may be inactivated.

A range of other chemical products are available that are recommended either as a food additive, water additive, or to apply directly to the cat’s mouth. Unfortunately there are few, if any, scientific studies to show that these products are effective in reducing gingivitis and the onset of periodontitis in cats.

Diets

There has been much debate about diet and the cause of periodontal disease. One study examined the difference between cats fed canned and dry foods compared with feral cats consuming a diet consisting of small mammals, birds, reptiles and insects.1 Twenty-nine feral cats and 20 domestic cats were included in the study.

The results showed that the dental calculus scores were significantly higher in domestic cats than in feral cats, but there was no statistical difference in the prevalence of periodontal disease between the two groups. A diet based on live prey does not protect cats against periodontal disease.

Commercial dental diets are available for cats and when fed as a complete diet have been shown to result in less plaque, calculus and gingival inflammation than a control group of cats fed another commercial dry food.

Hill’s t/d has a patented fibre matrix technology which allows the kibble to maintain contact with the tooth surface, providing mechanical cleansing. There are no abrasives or active chemicals in the kibble.

On the other hand, standard dry pet foods immediately crumble when chewed; therefore providing little mechanical removal of plaque compared to the Hill’s t/d kibble.

Royal Canin Cat dental diet has kibbles that are of a larger size than their standard kibble and this is claimed to have a mechanical plaque removing effect through the kibble texture shape. The ability of the Royal Canin dental diet to control dental accumulations is also maximized by the addition of sodium tripolyphosphate to the kibble. Sodium tripolyphosphate binds to salivary calcium, resulting in less of the mineral being available for calculus formation.

Both diets are highly recommended to help manage periodontal disease in cats.

Conclusion

The nurses role with owner education and encouraging compliance is essential in order to achieve good oral hygiene and dental care.

Periodontal disease remains one of the most common diseases affecting our domestic cat population, but preventive dental care is not easy. Whilst tooth brushing remains the gold standard and should always be recommended as first line management, studies have shown that owner compliance is not good.

Reinforced information at regular check ups and explaining the disease process to the owner helps with compliance, but always be prepared to offer other options when tooth brushing cannot be achieved. 

Author

Lisa Milella BVSC Dipl.EVDC MRCVS

Lisa graduated from the University of Pretoria (Onderstepoort), South Africa, in 1997 and has since been working in the UK. She soon developed an enthusiasm for dentistry and decided to pursue this interest to specialist level.

She is a Diplomat of the European Veterinary Dental College and principal of a dedicated dental and oral surgery referral practice in Byfleet, Surrey

To cile this article use either

DOI: 10.1111/j.2045-0648.2011.00137.x or Veterinary Nursing Journal Vol 27 pp 14-16

Reference

1. CLARKE. O.. CAMERON. A. [1998] Relationship between diet, dental calculus and periodontal disease in domestic and feral cats in Australia. Australian Veterinary Journal 76 [10]: 690-693.

Further reading

National Companion Animal Study, University ol Minnesota Centre for Companion Animal Health, 1996. p3.

LOGAN, E. el at. Dietary Control of Feline Gingivitis: Results of a 6-month study. American Dental Forum, Baltimore, 1999.

ROBINSON, J. (1995) Chlorhexidine gluconate – the solution to dental problems, Journal of Veterinary Dentistry 12 (1): 29-31.

• VOL 27 • January 2012 • Veterinary Nursing Journal