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Compendium April 2013 (Vol 35, No 4)

Dental Care for Senior Pets

by Heidi Lobprise, DVM, DAVDC

    Caring for senior patients can be a challenge because they seldom have just one problem or condition. Even with regular senior wellness visits and blood work, as internal organs get older, their function can diminish. Problems common in senior pets, such as cancer, heart disease, kidney disease, arthritis, and cognitive dysfunction, can have a tremendous impact on the quality of life of these patients. In light of these relatively important issues, the health of the oral cavity can be overlooked. However, oral care can play an integral role in keeping senior pets healthier overall.

    Systemic Impact of Oral Disease

    One of the biggest hurdles to providing optimal oral care for senior cats and dogs is that it typically requires general anesthesia, and concerns about anesthetic risks in light of a patient’s comorbidities may discourage the owner or even the veterinary team from pursuing adequate care. However, it has been shown that dogs exhibit an increase in the extent of periodontal disease with increasing age, especially smaller dogs.1 The inflammatory processes associated with the presence of dental disease and infection not only affect the oral cavity, but also may influence changes in systemic organs.2,3

    While it is difficult to prove a direct causal relationship (i.e., bacteria travel from the mouth through the bloodstream and infect a mitral valve or kidney), data suggest that an association exists between the extent of periodontal disease and histopathologic changes in the kidneys, myocardium, and liver.2 One study analyzed the estimated periodontal disease burden in toy and miniature poodles and correlated a higher burden with a higher likelihood of greater changes in the heart valves, liver, and kidneys.3 This study also addressed the possibility that nonoral conditions may be caused or exacerbated by circulating inflammatory mediators, chronic toxemia, and/or recurrent bacteremia from periodontal lesions. In human literature, this concept has been supported by the demonstration of persistently elevated levels of C-reactive protein (CRP) in people with advanced periodontal disease,4 and a study in which treating periodontal disease was associated with reducing inflammatory markers.5 The effect of periodontal therapy on reducing inflammatory markers in dogs was demonstrated in a recent study in which decreases in CRP concentration were seen after treatment and correlated with the severity of periodontal disease.6

    What may be difficult to prove unequivocally in a research setting, however, is the common clinical experience that once an owner is convinced that it is worth the risk of anesthesia to provide dental treatment to his or her elderly pet, the difference in the health and quality of life of that pet can be remarkable. And although there might not be a multicenter, blinded study to prove it, most veterinary professionals with some dental training believe that good dental health can improve a pet’s quality—and quantity—of life.

    Anesthesia

    To get to that state of better dental health, however, the hurdle of the anesthetic event must still be overcome. Trying to circumvent anesthesia risks by attempting “anesthesia-free dentistry” is not a reasonable choice, and the American Veterinary Dental College (AVDC) and the American Animal Hospital Association (AAHA) have guidelines against such procedures.7,8 As stated in the AAHA Dental Care Guidelines for Dogs and Cats, this practice “reduces the ability to make an accurate diagnosis, does not allow adequate treatment, and increases stress and risks to the patient.”8Even if hand-scraping the teeth may give a better cosmetic appearance, the owner is given a false sense of security, and a serious problem could be neglected.

    A thorough preoperative assessment, including history, physical examination, blood work, blood pressure measurement, and thoracic radiography, can help alert the veterinary team to underlying conditions that could affect the anesthetic event. General anesthesia guidelines can be found in many resources, including the AAHA Senior Care Guidelines for Dogs and Cats.9 The following is an overview of some of the issues that might be of even greater concern in dental procedures.

    Coexisting Disease

    Renal, cardiac, hepatic, and thyroid diseases are common in senior pets and require consideration when planning anesthesia for an affected patient.

    • Stabilize the patient to the best extent possible before the anesthetic event.
    • Diabetes and periodontal disease are comorbidities in many patients. Treating periodontal disease can help with regulation of diabetes in some patients.

    Antibiotic Administration

    • While it is essential to use antibiotics responsibly, dogs and cats undergoing anesthesia for dentistry face the following:
      • Bacteremia
      • Possible hypovolemia and hypotension (unlike human patients)
      • Possible hypothermia

    If organ systems could be affected by stress and bacteremia, consider administering a broad-spectrum antibiotic before the procedure starts.

    • Some patients with significant oral infection may benefit from antibiotic administration for several days before the procedure to reduce the bacterial burden.
    • During the procedure, determine if the patient needs postoperative antibiotics and, if so, the appropriate agent(s) and duration of therapy.
      • A broad-spectrum antibiotic such as amoxicillin-clavulanic acid may be optimal due to the wide variety of bacteria found in oral infections; depending on the patient’s immune status and depth of infection, 7 to 10 days of therapy is often recommended.
      • Infections that invade bone may require clindamycin until they are under control.

    Polypharmacy 

    • Obtain a complete list of all medications the patient is receiving, even over-the-counter drugs and supplements; some (certain fatty acids, NSAIDs) may need to be discontinued if they can contribute to lower platelet function.
    • Review which medications the owners need to give on the morning of the procedure and which they can withhold.
    • Be aware of which medications can affect anesthesia and recovery.
    • Set up a specific insulin and feeding schedule for diabetic patients to take preoperative fasting and postoperative dietary needs into account. Perform sequential blood glucose measurements during anesthesia to monitor for significant fluctuations.

    Pain Management

    • Assume that the dental procedure will be painful. Even if no extractions are done, manipulation of the temporomandibular joint and periodontal scaling can cause discomfort.
    • Good preoperative analgesic combinations can allow the use of less injectable anesthetic for induction and lower levels of inhalant anesthetic during the procedure.
    • Local and regional blocks help control pain before it intensifies so that less general anesthesia is required.
    • Maintain analgesia and carefully repeat doses if warranted.

    Hydration

    • Some dental procedures may take a long time, and oral consumption may be decreased postoperatively for a while.
    • Consider allowing the patient to consume minor amounts of water early in the morning.
    • Early placement of an intravenous catheter can allow for fluid preloading when indicated.
    • Monitor kidney output if necessary.
    • Watch for signs of overhydration.

    Body Temperature

    • Many senior dental patients are smaller and lose body heat more readily; therefore, hypothermia can be exaggerated in these patients.
    • Dental procedures often expose the patient to water, so keep the patient as dry as possible.
    • A body temperature below 98°F (36.7°C) may alter mentation, cardiac function, and healing.10

    Patient Monitoring

    While not unique to dentistry, good monitoring during the procedure is essential. The technician performing the dental cleaning should not also be responsible for monitoring.

    • Hypotension is a critical factor during surgery. Maintain the mean blood pressure between 80 and 120 mm Hg and the systolic blood pressure between 100 and 160 mm Hg for optimal perfusion.
    • Closely monitor oxygen saturation with pulse oximetry (Spo2). An Spo2 >95% is considered normal.
      • An Spo2 <90% signals serious hypoxemia. Determine if modification to depth of anesthesia or delivery of oxygen can correct Spo2 sufficiently to continue the procedure.
      • An Spo2 <75% indicates very serious hypoxemia. Discontinue the procedure and take significant measures to maintain the airway and stimulate respiration, including cardiopulmonary resuscitation.
    • Maintain end-tidal CO2:
      • Between 35 and 40 mm Hg when patient is awake
      • Between 40 and 50 mm Hg when patient is in a light surgical plane
    • Closely monitor body temperature and maintain body temperature support devices throughout the procedure.

    Procedure Length

    Some patients benefit from staged procedures.

    • Avoid excessively long procedures (>3 hours).
    • Perform initial or scheduled therapy to get the primary infection under control.
    • If initial therapy reveals the need for extensive oral surgery, schedule the more extensive procedure for a later date.
    • Set expectations with owners if extensive work is anticipated (e.g., full-mouth extractions).

    Recovery

    Patient management is very important during the recovery period.11

    • Make sure the pharynx is clear of all fluid and debris.
    • Maintain the airway for as long as possible, especially in brachycephalic breeds.
    • Maintain fluid administration until discharge, if possible.
    • Monitor urine output.
    • Monitor for hypothermia and bradycardia.
    • Maintain adequate analgesia.

    Discharge

    • Review all dental records, radiographs, and care instructions with the owner before the patient is brought up.
    • Dispense pain medication and antibiotics when appropriate.
    • Schedule a recheck appointment for 2 weeks; review home care at that time.

    Senior Pet Dental Issues

    Periodontal Disease

    As stated above, without intervention, periodontal disease gets progressively worse as pets age, particularly in smaller dogs (FIGURE 1). In patients with smaller amounts of bone mass, even minor levels of bone loss can be significant. Common problems caused by periodontal disease include:

    • Rostral mandible compromise: Bone loss can lead to incisor and even canine loss and eventual symphyseal instability.
    • Maxillary canine fistula: Deep periodontal pockets on the palatal aspect of the teeth can destroy the thin layer of bone leading to the nasal cavity, forming an oronasal fistula that requires deliberate surgical technique.
    • Compromised mandible: Bone loss at the level of the large first molar can lead to pathologic fractures, either before the procedure or while the tooth is being extracted.
    • Periodontic-endodontic lesion: Periodontal bone loss that extends down the entire root can allow bacteria in through the apex and destroy the rest of the pulp. A common site for this lesion is the mandibular first molar with periodontal bone loss down the distal root.

    Tooth Trauma

    Dogs that have been chronic chewers for their entire lives may have damaged crowns and roots. If wear is gradual enough, sometimes the pulp retreats behind reparative dentin, whereas acute trauma can fracture a tooth and expose the pulp. Even if the pulp is not exposed, consistent stress on the roots can lead to loss of the periodontal ligament space and ankylosis of the tooth to the surrounding alveolar bone. By itself, this is not a serious problem as long as the tooth remains vital, but if the tooth needs extraction, simple elevation of the tooth will be complicated because the periodontal ligament cannot be loosened. Teeth that have pulpal compromise (exposed canal or discolored) are nonvital and require either extraction or root canal therapy.

    Feline Dental Problems

    Chronic Alveolitis/Osteitis

    Chronic alveolitis/osteitisis seen in older cats and presents as a supereruption of the maxillary canines (FIGURE 2) with thickening of the alveolar bone or bulging. If the inflammation and extrusion are severe enough to cause significant periodontal pocket formation or tooth mobility, the tooth should be extracted. Performing a routine flap on the paper-thin gingiva can be challenging, so careful elevation of the flap followed by osseous remodeling may be necessary to close the flap after curetting and flushing out the alveolus. The affected teeth should be closely evaluated for evidence of resorption and the impact on the decision to extract.12 If the tooth is still stable, a thorough cleaning and periodontal treatment may arrest the changes, but the tooth tip should be gently blunted to help prevent trauma to the opposing lip, which can occur in some cases due to hyperextrusion.

    Tooth Resorption

    Tooth resorption is a broad term used to describe any loss of dental hard tissue (enamel, cementum, or dentin). It is common in cats of all ages, including senior cats. Intraoral radiographs to identify the presence or lack of a periodontal ligament space are critical in determining the course of treatment. A common type of resorption involves destruction of the periodontal ligament as the root is apparently being transformed into bone (type II resorption). Without a periodontal ligament, typical elevation is not possible, so a modified form of extraction may be necessary, in which the resorbing roots are intentionally retained as long as (1) no periapical lesion is seen, (2) there is no existing periodontal disease, and (3) the patient has not been diagnosed with stomatitis.13 In contrast, an inflammatory (type I) resorption of the root due to periodontal disease may look the same grossly, but radiography reveals a distinct focal area of tooth resorption associated with the region of periodontitis, and the periodontal ligament beyond that region appears intact. These roots must be completely elevated during extraction. For further descriptions and illustrations, see the AVDC Web site

    Stomatitis

    Stomatitisis a broad term used to describe a variety of syndromes characterized by a disproportionate amount of gingival inflammation, ulceration, and proliferation given the amounts of plaque and calculus on the teeth. While stomatitis is not a problem specific to older cats, any ulceration that is unusual or slow to heal should be biopsied to rule out any neoplastic or other immune dysfunction. In most cases, extraction of any moderately to significantly affected teeth is the minimum therapy recommended, as regular home care and periodontal therapy are less likely to occur in many senior cats. Some cats with refractory stomatitis may require full mouth extractions and additional medical therapy to maintain quality of life. For more information on oral and oropharyngeal inflammation, see the AVDC Web site.

    Oral Tumors

    With increased longevity comes the increased likelihood of developing cancer, and cancer of the oral cavity is no exception. With the exception of some fibrosarcomas that are more typically found in younger dogs, oral tumors increase in frequency in older animals. Dogs may develop melanosarcoma, osteosarcoma, and squamous cell carcinoma, while the most common oral tumors in cats are three types of squamous cell carcinoma: gingival, lingual, and tonsillar. Early detection is critical to have any chance of successfully treating most oral tumors, which can sometimes be treated by radical surgery or, infrequently, radiation therapy.

    Conclusion

    While older patients have similar dental issues as younger ones, many progressive diseases, especially periodontal disease, can take a greater toll during a pet’s golden years. The compounding factor of needing anesthesia may sometimes keep these pets from being treated, but a healthy oral cavity will help their quality of life.

    Downloadable PDF

    A downloadable PDF of this article will be available soon.

    Dr. Lobprise is a senior technical manager for Virbac Animal Health.

    References

    1. Harvey DE, Shofer F, Laster L. Association of age and body weight with periodontal disease in North American dogs. J Vet Dent 1994;11(3):94-105.

    2. DeBowes LJ, Mosier D, Logan E, et al. Association of periodontal disease and histologic lesions in multiple organs from 45 dogs. J Vet Dent 1996;13(20):57-60.

    3. Pavlica Z, Petelin M, Juntes P, et al. Peridontal disease burden and pathological changes in organs of dogs. J Vet Dent 2008;25(2):97-104.

    4. Linden GJ, McClean K, Young I, et al. Persistently raised C-reactive protein levels are associated with advanced periodontal disease. J Clin Periodontol 2008;35:741-747.

    5. Montebugnoli L, Servidio D, Miaton RA, et al. Periodontal health improves systemic inflammatory and haemostatic status in subjects with coronary heart disease. J Clin Periodontol 2005;32:188-192.

    6. Rawlinson JE, Goldstein RE, Reiter AM, et al. 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(5):601-609.

    7. American Veterinary Dental College. Position Statement. Companion Animal Dental Scaling Without Anesthesia.http://avdc.org/statements.html. Accessed March 2013.

    8. Holmstrom SE, Bellows J, Juriga S, et al. 2013 AAHA dental care guidelines for dogs and cats. J Am Anim Hosp Assoc 2013;49:75-82.

    9. Epstein M, Kuehn N, Landsberg G, et al. AAHA senior care guidelines for dogs and cats. J Am Anim Hosp Assoc 2005;41:1-11.

    10. Armstrong SR, Roberts BK, Aronsohn M. Perioperative hypothermia. J Vet Emerg Crit Care 2005;15(1):32-37.

    11. Ko J. Patient management during recovery most important part of anesthesia. DVM Newsmagazine 2001;Mar:25-32.

    12. Lewis JR, Okuda A, Shofer FS, et al. Significant association between tooth extrusion and tooth resorption in domestic cats. J Vet Dent 2008;25(2):86-95.

    13. DuPont G. Crown amputation with intentional root retention for advanced feline resorptive lesions—a clinical study. J Vet Dent 1995;12(1):9-13.

    References »

    NEXT: Sago Palm Toxicosis in Dogs

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