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Veterinarian Technician February 2005 (Vol 26, No 2)

Educating Clients About Preventive Dentistry

by Mary L. Berg, BS, RVT, RLATG

    Key Points

    • Veterinary dental home care is not intended as a replacement for professional dental care but as an adjunct to that care.
    • Oral disease can be controlled with proper home care and regular veterinary dental examinations and prophylaxis.
    • The technician's role in preventive dentistry is to educate clients, demonstrate and assess brushing techniques, and recommend quality dental products.

    Pet owners are often surprised to learn that their pets need dental care, including regular toothbrushing. They are even more surprised when they are told that periodontal disease is one of the most prevalent diseases in adult dogs and cats.1,2 Because oral disease can be prevented or controlled with proper home care and regular dental prophylaxis, veterinary technicians can play an important role in client education.

    Because technicians interact so closely with clients, they play a key role in several areas, including explaining the risk factors associated with oral disease, demonstrating proper techniques for brushing a pet's teeth, and recommending appropriate dental products. A client who understands the importance of oral care may be more willing to perform routine home care to help ensure that his or her pet maintains a healthy mouth. A healthy mouth leads to an overall healthier patient, which in turn makes the client happy. In addition, by taking the time to educate clients about proper dental care, technicians can help develop a strong relationship between the client and the clinic.

    Providing Educational Materials

    There are many ways to educate clients about the importance of dental health for their companion animals. Some companies offer professionally produced educational materials, such as brochures, handouts, and posters, that cover one or more aspects of oral health. Clinics may also choose to create their own client education materials (e.g., pamphlets, flyers, forms with reminder messages). Pamphlets should contain information about the prevalence of oral disease, the possible relationship between periodontal and systemic diseases, preventive dentistry recommendations, and which dental services are offered at the clinic.

    Visual aids (e.g., posters hanging in the treatment room) can be extremely effective in delivering the message about the importance of good dental home care to the client. In addition, visual aids can show clients how oral disease may lead to problems in other areas of the body, such as the heart, liver, and kidneys. Comparison pictures showing a healthy mouth and a diseased mouth can also be quite effective. For a hands-on approach, plastic models of a mouth with a healthy side and a diseased side can be used.

    Providing a handout that can be individualized for each patient is another way of showing the client the importance of good dental health. The handout can include a simplified dental chart on which the technician has made notations (e.g., probe depth, furcation formation, tooth loss). These notations should then be discussed with the client to ensure they understand the significance of the problems. The prescribed treatment plan can be included on this handout so the client can then take it home with him or her as a reminder of the dental treatment that is needed.

    The best time to begin educating clients about the importance of preventive dentistry is during their very first visit to the clinic. This is ideally a puppy or kitten visit. When clients begin home care while their pet is very young, the experience can be much more enjoyable for both the owner and the animal. Many clinics give clients a new puppy or kitten goody bag that includes items such as a food sample, heartworm treatment, or flea control product. To promote dental care, clinics can also provide a pet toothbrush that has the clinic's name and phone number stamped on the handle. These relatively inexpensive brushes can be purchased from dental supply companies. By mentioning home dental care during every visit to the clinic, technicians can ensure that this topic becomes a natural part of the technician-client dialogue.

    Reviewing the pet's dental charts and radiographs with the client is another way to help educate the client and make him or her feel important in their pet's diagnosis and treatment. This reinforces the significance of dental health and helps the client better understand what treatment is necessary.

    Explaining Plaque, Calculus, and Periodontal Disease

    It is important to explain to clients that dental plaque is a soft gelatinous material that forms within hours on a cleaned tooth surface. Plaque is composed of aggregates of bacteria and their by-products, salivary components, oral debris, and occasional epithelial and inflammatory cells.1 Mature dental plaque calcifies into dental calculus or tartar. The bacteria in the plaque begins to destroy the gingiva, leading to periodontal disease. Periodontal disease includes gingivitis and periodontitis. Gingivitis is a reversible condition affecting the gingival soft tissues; it can be treated and largely prevented with thorough plaque removal and continued supragingival plaque control. If left untreated, however, gingivitis can progress to the more severe and irreversible condition, periodontitis. Periodontitis is characterized by localized inflammation and the destruction of periodontal tissues, including loss of the bone supporting the tooth as well as tooth loss.2 There is increasing evidence that periodontal disease affects systemic health based on a positive correlation between the severity of the periodontal disease and histopathologic changes in the kidney, myo­car­dium, and liver.3

    The most important strategy in the prevention of periodontal disease is plaque control.4 Regular toothbrushing has always been the "gold standard" for plaque control if this option is chosen by the client and accepted by the pet. Very simply, brushing the teeth helps control plaque and periodontal disease. It is critical for clients to understand that daily cleaning of their animal's teeth with a toothbrush is not a "routine activity" as it is in humans but a habit that must be developed by most clients. Clients should be given information so that they understand the importance of routine brushing. The technician should also demonstrate to the client how to properly brush his or her pet's teeth and encourage them to make a commitment to do it daily.5 Although effective plaque control can be achieved by daily brushing, this should not take the place of regular visits to the veterinarian for professional dental checkups. It is important to tell clients that just as humans should visit the dentist every 6 months and regularly brush their teeth, comprehensive dental care is also essential for their pet. The frequency of the visits should depend on the animal as well as the client's economic situation.

    When recommending toothbrushing, it is important to advise clients that they should not use toothpaste designed for humans because animals may swallow it. Human toothpaste has higher amounts of detergent that may upset a pet's gastrointestinal system. In addition, the ingestion of high levels of fluoride may be toxic. Studies conducted at the University of Kansas demonstrate that brushing with water alone can be as effective as brushing with a dentifrice.6 An advantage of using a flavored animal toothpaste is that it may help with the pet's acceptance of the toothbrush in its mouth.

    Daily brushing can be encouraged by pointing out that the experience can be positive for both the client and the pet. The brushing ritual can become a quality bonding time. Pets that have their teeth brushed on a regular basis will often begin to beg at the set brushing time because they know that this is an important one-on-one time with their owner. In addition to helping a pet maintain good health, daily brushing can enhance the human"animal bond. Technicians can also encourage clients to involve their children in the brushing process. This helps emphasize the importance of oral care to children and helps them grow up to be informed pet owners.

    Compliance Assessment

    The technician should discuss oral care with the client to determine the willingness and ability of the client to perform dental care at home. Not all clients are concerned about delivering the home care that their pet requires. This may be due to a lack of interest, motivation, knowledge, or understanding, or the inability to physically perform the task. These factors along with the animal's temperament and tolerance of the procedure need to be taken into consideration before prescribing a home care regimen. The decision to save a tooth or extract it depends on the client's desire and ability to comply with home-care instructions.4 If brushing the pet's teeth is not an option, there are other alternatives for plaque control, which are discussed later.

    Demonstrating Proper Brushing Technique

    To ensure that the pet receives the best possible home care, it is important to demonstrate the proper brushing technique to remove dental plaque. A good first step is to use a plastic model to demonstrate the correct position and motion of the toothbrush. Use of the model eliminates the need for animal restraint and allows the client to see the action of the brush without the obstruction of the animal's lips.

    There are varying opinions on what constitutes correct technique when brushing a pet's teeth. Ideally, the brush should be held at a 45° angle to the gum line using a circular motion.5 It is recommended to brush the animal's teeth for at least 30 to 60 seconds per side. The teeth should be brushed for approximately 30 seconds per quadrant, including only the buccal (outside) surfaces. The tongue is very good at keeping the lingual surfaces clean.

    Regardless of the method preferred, the technician should explain that not only is brushing important, but it must be effective. The client should be reassured that brushing the buccal surfaces is sufficient; however, if the pet is very cooperative, the client can also brush the lingual surfaces. This can best be done by placing an object such as a rubber bone between the jaws to help access the lingual surfaces. The technician should also make it clear that all teeth should be brushed, including the back molars and the incisors.

    After demonstrating the brushing technique on the model, the technician can then brush a cooperative demonstrator animal. This allows the client to see how the procedure is performed on a real animal. If the client's pet is cooperative, the technician should try brushing its teeth. The technician can brush one side of the mouth and guide the owner while he or she brushes the other side. By doing this, the technician has an opportunity to see how the animal reacts to brushing and can then give pointers and advice that may make brushing more acceptable to both the pet and owner.

    If the client's pet is not ready to accept having its teeth brushed, methods should be suggested to aid the owner in training the pet to accept the toothbrush. Several steps can be taken to help acclimate the pet to the toothbrush and procedure.a The key is to begin slowly. First, the client should be instructed to offer the pet flavored toothpaste on the toothbrush and let the animal lick it off the brush. There should be no attempt to brush or restrain the animal during this process.5 After the animal becomes comfortable with the brush, the next step is to try brushing only one or two strokes and a few teeth. Eventually, the animal will accept having its teeth brushed. Another method that can be used is to wrap a finger with a gauze pad and gently wipe the teeth. This can be done until the animal accepts the handling of its mouth, and then brushing the teeth can be gradually introduced. To get a cat to accept the toothbrush, it can first be dipped in tuna juice. Brushing at approximately the same time and place each day can reduce stress and help owners remember the routine.

    Dogs may try to back away from the owner during brushing. To limit backward or sideways motion but avoid making the animal feel confined, the technician can suggest that the owner set the dog in a corner. Cats respond best to very little restraint while brushing.

    Positive reinforcement is essential in training a pet. The technician should inform the owner that the pet should be rewarded during and after brushing. These rewards can include constant praise, a game involving the pet's favorite toy, a walk, or even a treat. Cats and small dogs may enjoy sitting on their owner's lap so that they can cuddle while their teeth are being brushed.

    After a home care routine is instituted, it should be continually monitored and reinforced. Clients should be encouraged to call or return to the clinic whenever necessary if they have questions or concerns about brushing their pet's teeth. The technician plays a vital role in educating the client, monitoring compliance, and reinforcing the message about the importance of home dental care.3

    Alternatives and Adjuncts to Brushing

    Although brushing a pet's teeth is the gold standard for plaque control, it is not always an option. If brushing is not possible, there are many products available that offer plaque reduction or removal. There are three types of plaque control: mechanical, chemical, and barrier.

    Mechanical Plaque Control

    Mechanical plaque control is the means of controlling plaque by the use of a device or the act of mastication. Although the most effective mechanical method of plaque control is the toothbrush, special diets and toys can also help control plaque.

    Dental Diets

    Diet can be part of a complete preventive dental program. Several diets are specifically designed to remove plaque from canine and feline teeth. Quality products have the Veterinary Oral Health Council (VOHC) seal of approval on their label. These ap­proved diets have a texture and size that allows the tooth to penetrate the kibble, creating a squeegee effect that mechanically removes plaque, much like a "consumable" toothbrush. Many of these dental diets are not only effective in reducing plaque accumulation but also help reduce malodor or bad breath.

    Other dental diets are available that offer technology that could be considered chemical rather than mechanical. These diets are designed to prevent tartar buildup by the addition of sodium hexametaphosphate, a calcium chelator.

    Treats and Chews

    Treats often claim to deliver "fresher breath and whiter teeth." These label claims should be evaluated on an individual basis. There are many products that do a good job at helping to reduce plaque formation and have been awarded the VOHC seal of approval. Some chew toys (e.g., cow hooves, pig ears, bones) should be avoided because they are too hard and may fracture the pet's teeth. It is also important to remind owners that chews can be a choking hazard. In addition, when giving a pet any type of treat, the caloric intake of the treats should be factored into the pet's daily requirements.

    Toys

    Several toys on the market offer some dental benefit for pets. Just as with children, however, any toy or chew can easily become a health hazard. Clients should be encouraged to evaluate toys carefully before purchasing them to make sure that the toy is not too hard on the pet's teeth and that there are no pieces that may come off during playtime. Some acceptable toys include rope, Kong (Kong Veterinary Products, Golden, CO), or Booda (Aspen Pet Products, Inc, Denver) products.

    Chemical Plaque Control

    Chemical control of dental plaque can complement a good mechanical oral hygiene program. There are many options for the chemical control of plaque.

    Some of the most commonly used and more effective products contain chlorhexidine gluconate. The advantage of chlorhexidine gluconate is its substantivity, or the ability to adhere to oral tissues and release its agents slowly.4 Many products, including toothpastes, rinses, and gels, are labeled to contain chlorhexidine as the digluconate or diacetate. Chlorhexidine reacts with tooth surface debris to form a dark stain that may be easily removed by a professional dental prophylaxis.

    Zinc is another chemical that is effective in controlling plaque and stimulating the healing of oral tissues. Neutralized zinc gluconate that is stabilized with taurine creates a taste-free gel. This neutralized zinc delivers higher zinc bioavailability to the gingiva and plaque. This oxidizes anaerobic bacteria and reduces gingival inflammation. The sulfur amino acid, taurine, chelates with the sulfur compounds and absorbs malodorous activity.

    There is some controversy as to whether fluoride is necessary for veterinary dental health. In humans, fluoride is used to prevent caries. Because animals rarely get carious lesions, however, many individuals have questioned the need for daily or professional topical fluoride treatments. High concentrations of fluoride can be antimicrobial and thus are used by some professionals as part of a dental prophylaxis. Stannous fluoride has the ability to be antimicrobial and is stable at a pH of 6.5.4 The 0.4% strength should be used but only sparingly. Many practitioners use fluoride as a final step in the prophylaxis process. Monofluoride phosphate is used in human dental products; but because of its acidity, this product should not be recommended for home care for pets.

    Barrier Plaque Control

    A plaque barrier system for pets, which is a biologically inert, electrostatically charged, wax-like polymer that adheres to the tooth's surface, has been developed. This polymer reportedly produces an invisible barrier that reduces plaque and tartar accumulations by preventing bacteria from adhering to the tooth surface. The barrier is placed on the pet's teeth as the last step in a prophylaxis and then applied weekly as part of a home care regimen. It is designed to withstand regular brushing, dental diets, and chew toys.

    Conclusion

    Dental home care is not intended as a replacement for professional dental care but as an adjunct to that care. The key to effective home treatment is compliance. The role of the technician is to assist the veterinarian in assessing the client and pet to see which type of home care is most appropriate, educating the client about proper brushing and product use as well as the risk factors of oral disease, demonstrating the techniques for proper home care, and providing valid evidence-based recommendations that will benefit both the owner and pet. Following these guidelines will help make sure that clients understand the importance of providing dental care for their pets.

    1. Logan EI, Boyce EN: Oral health assessment in dogs: Parameters and methods. J Vet Dent 11(2):58-63, 1994.

    2. Harvey CE, Emily PP: Periodontal disease, in Harvey CE, Emily PP (eds): Small Animal Dentistry. St. Louis, Mosby, 1993, pp 89-144.

    3. Logan EI, Finney O, Hefferren JJ: Effects of a dental food on plaque: Accumulations and gingival health in dogs. J Vet Dent 19(1):15-18, 2002.

    4. Holmstrom SE: Home-care instruction, in Holmstrom SE (ed): Veterinary Dentistry for the Technician and Office Staff. Philadelphia, WB Saunders, 2000, pp 183-194.

    5. Gorrel C: Preventive dentistry, in Gorrel C (ed): Veterinary Dentistry for the General Practitioner. Philadelphia, WB Saunders, 2004, pp 111-118.

    6. Logan EI, Berg ML, Coffman L, Hefferren JJ: Scientific basis for prevention. Proc 14th Vet Dent Forum:261-264, 2000.

    References »

    NEXT: On the Cover: A Talk with AVDT President Jeanne Vitoux, CVT

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