Dental disease is extremely common. Between 50-90% of cats over 3 years of age have some degree of plaque, tartar, gingivitis, and periodontal disease. Without regular care at home and in the veterinary clinic, plaque and tartar will result in gingivitis and periodontal disease. Additionally, many cats experience other painful dental conditions including tooth resorption and chronic gingivostomatitis.
Oral Healthcare at Home
Oral healthcare should be discussed at every preventive healthcare visit. A discussion of home care options should include the daily brushing or wiping of a cat’s teeth. Recommended products such as therapeutic diets and treats should be verified by the Veterinary Oral Health Council (VOHC) for claims for control of plaque and tartar. Working with their veterinarian, clients should be encouraged to develop a routine home care protocol that comprises daily brushing as well as the use of one or more VOHC verified products. However, daily home care should not be started in an unhealthy mouth as it will cause pain and delay appropriate treatment. Home care options are best employed in young cats with a healthy mouth, or after dental assessment and treatment in an older cat. The use of dental treats or diets should be incorporated into the patient’s nutritional program to avoid excessive caloric intake.
Home Care Packages
- Tooth brush: A variety of types should be provided, as each cat will vary in acceptance of different tooth brush types.
- Wrapping a 2 inch gauze square around a finger may be a more acceptable approach for wiping plaque from a cat’s teeth on a daily basis.
- Veterinary toothpaste samples: While the act of physically removing dental plaque is key in the prevention of disease, toothpaste may aid in the removal, and may also be used to encourage the cat to chew on the tooth brush.
- Dental information pamphlet.
- Small sample of VOHC-approved dental kibble.
Oral Healthcare in Clinic
Clients need to be aware that just like brushing their own teeth, preventive dental care will help retard dental disease but cannot completely prevent it from occurring. Routine assessment under anesthesia including a full oral health assessment and full mouth dental radiographs are a key component to identifying hidden disease. Clients should understand that these procedures also help identify tooth resorption, which can be hidden under the gum line.
A thorough examination of the oral cavity should be an essential component of every physical examination. In most cats, a thorough examination of the oral cavity and dental crowns is achievable when the patient is awake. However, some cats may be reluctant to allow oral examination. This reluctance may stem directly from the presence of oral pain, arthritis pain, or a general reluctance to be handled. Clients should be made aware that analgesics, sedation, or anesthesia may be required for a basic examination to be completed. Hand scaling of teeth in an awake or conscious cat is not recommended and is not a substitute for a comprehensive oral health assessment and treatment plan (COHAT) under general anesthesia. Hand scaling may cause trauma to the cat or the veterinarian, does not address dental care needs, and may mislead the client into thinking nothing further is required.
During an oral health examination, the following should be documented in the medical record:
- The presence/absence of specific teeth.
- The presence and identification of fractured teeth.
- The degree of tartar and gingivitis.
- The presence of mobile teeth.
- The presence of visible tooth resorption lesions.
- Areas of inflammation, swelling, or masses.
- Oral odours and if possible, its source.
The client should be aware that oral examination on the awake patient does not provide information about:
- Tooth root disease.
- Subgingival disease including pockets.
- Some mobile teeth.
- Resorptive lesions concealed by oral and gingival structures.
- Masses, inflammation, or other lesions concealed by oral and gingival structures.
All examination findings should be properly recorded in the medical record. A treatment plan and estimate of costs should be made and discussed in detail with the client.
It is the veterinarian’s responsibility to relieve the patient’s immediate pain. Analgesics should be prescribed the day that painful dental disease is diagnosed. Concern with the patient’s status will be further impressed upon the client if the clinician encourages the client to pursue pre-anesthetic testing on the day of diagnosis, as well as scheduling the surgical procedure before leaving the veterinary clinic.
Complete Oral Health Assessment and Treatment
Once under anesthesia, the patient should undergo detailed oral evaluation. Detailed oral evaluation includes assessment of each tooth for visible and palpable disease, as well as assessment of each tooth by dental radiography. The failure to perform dental radiographs will result in a failure to identify sub-gingival disease that can be of significant importance. As such, all feline dentistry should include full mouth radiography. All findings should be recorded on a standardized dental chart using standard nomenclature. Teeth requiring surgical extraction or other therapy should be recorded. All teeth with identified pathologic disease should undergo appropriate treatment or the patient should be referred for specialist care. Following care of the diseased teeth, or in the absence of diseased teeth, professional cleaning should ensue. This should include scaling and polishing by a licensed veterinarian or veterinary technician.
Pain Management in Dental Surgery
Oral lesions present in the feline mouth are painful. This pain persists even under general anesthesia. The patient should be provided with a balanced anesthesia and multimodal analgesia plan in order to reduce or eliminate existing pain and to reduce surgical and post-surgical pain. This approach should include pain management prescribed on the day of diagnosis. During the COHAT, a constant rate infusion of pain management drugs may benefit the anesthesia status for patients requiring extractions as well as improve recovery. The patient should receive local dental nerve blocks prior to surgical procedures. Immediately postoperatively and for 1-2 weeks following the surgical procedure, the patient should receive multimodal analgesia including (where appropriate) non-steroidal anti-inflammatory drugs, narcotics, and other pain management drugs such as gabapentin.
Post-operatively, follow-up communication by telephone with the client is critical in the immediate days following surgery to ensure appropriate recovery, compliance with medication, and sufficient consumption of food. A recheck appointment should be scheduled 2 weeks following surgery. Depending on the nature of the dental pathology identified, an appropriate home dental care plan should be recommended to the client. Home dental care plans should never be started while the mouth is painful and unhealthy. It is best to wait until disease has been treated and the mouth has healed.
The Use of Antibiotics in Dental Disease
The domestic cat has well over 200 species of bacteria living in its oral biofilm. The presence of tartar and gingivitis, while being a function of the presence of these bacteria, is not an indication for the use of antibiotics. Except in cases where abscesses exist, the provision of analgesics and urgent pursuit of dental surgical care constitutes the appropriate route of treatment. The removal of diseased teeth and the removal of plaque and tartar reduce any perceived need for antibiotics. The use of antibiotics may disturb the normal oral or gastrointestinal flora, are likely of no long-term benefit to the patient, particularly if the primary issues are not addressed and are a concerning contribution to the development of antimicrobial resistance. Where extraction of diseased teeth is sufficient to eliminate risk of infection, the use of antibiotics is considered excessive and should not be pursued.
Resistance to Dental Care
Clients may be reluctant to pursue dental care for a variety of reasons. These may include:
- A fear of anesthesia, especially in elderly cats. Veterinarians must acknowledge and address client concerns regarding anesthesia but should not recommend less-than-optimal dental care.
- An inability or unwillingness to pay the costs associated with a COHAT. A well-established veterinary-client-patient relationship (VPCR) can be beneficial in the understanding and acceptance of related costs. Individual clinics may elect to offer payment plans or third-party financing in order to expedite the necessary surgical care.
- An inability to recognize that the cat’s dental disease is causing their cat any discomfort. A well-established VPCR will ensure the trust necessary to overcome this objection. In addition, the immediate use of analgesic medication in advance of dental surgery will improve the client’s understanding and acceptance of the patient’s oral pain.
- Specific dental conditions
Feline tooth resorption (TR) is a destructive process that is found in 30-70% of cats. Older names for this condition include feline odontoclastic resorptive lesions, feline resorptive disease, and neck or cervical lesions. Regardless of the terminology, the cause of this painful condition remains unclear. Classification of tooth resorption is currently divided into five types of tooth pathology or three types of radiographic changes. These classifications are set by the American Veterinary Dental College.
Tooth resorption affects 27–72% of domestic cats and is caused by the odontoclastic destruction of teeth. Although the etiology of these lesions still remains unproven, gingival inflammation and exposure of the pulp chamber causes various painful stages as the disease process progresses.
The Types of Resorption Based on Radiographic Appearance
- Type 1 TR: Focal or multifocal radiolucency, with the remainder of the tooth having normal radiopacity and a normal periodontal ligament space.
- Type 2 TR: Narrowing or disappearance of the periodontal ligament space in some areas, as well as a decreased radiopacity of part of the tooth.
- Type 3 TR: Features of both Type 1 and Type 2 are present in the same tooth. The periodontal ligament will have normal areas and areas of loss or narrowing. The tooth will have multifocal radiolucent areas as well as decreased radiopacity in other areas.
Regardless of the lesion type, the condition is progressive and painful. Extraction of affected teeth is the only rational treatment approach. Dental radiography of all teeth is essential. Affected crowns may have diseased tooth roots, which is critical information when planning surgical extraction. Radiography will also allow the identification of developing TR at the root level that may not be apparent in the crown. These teeth also require extraction. Crown amputation is recommended only in specific situations.
Cats that have been diagnosed with TR are known to be at increased risk of developing further lesions in the future. Monitoring at regular intervals should include an annual COHAT with dental radiography. This will allow for early identification and extraction of affected teeth.
Currently, there is no known method for the prevention of TR. Good dental hygiene continues to be of importance for the control of other dental conditions, although the role in the prevention of TR is not yet clear.
Feline Chronic Gingivostomatitis
The presence of oral inflammation that is inconsistent with the degree of plaque and tartar may be indicative of feline chronic gingivostomatitis (FCGS). The inflammation present in FCGS will often extend beyond the gingiva to nearby oral tissues including the back of the mouth, throat, and under the tongue. Feline chronic gingivostomatitis occurs as a result of an abnormal local immune system response. The origin of this response is unknown. Gingival biopsy helps differentiate FCGS from other oral diseases, especially neoplasia, in certain cases. The condition may be temporarily responsive to medications including certain antibiotics or corticosteroids. Dental scaling may alleviate the condition for short periods. Therefore, full mouth extraction of all teeth and roots is considered the appropriate treatment in severe cases, although the response rate may not be 100% for all patients. Delay in pursuit of full mouth extraction may reduce the success rate of this procedure, as the inflammatory response continues to worsen. During surgical extraction for FCGS, full mouth radiographs prior to extraction and following extraction are necessary, to identify root abnormalities prior to extraction and identify and retrieve root remnants following extraction. Crown amputation is recommended only in specific situations. Patients with FCGS should be tested for feline immune deficiency virus and feline leukemia virus.
FELINE SPECIALIST AUTHORS
- Susan Little, DVM, DABVP (Feline Practice) Bytown Cat Hospital, Ottawa, Ontario
- Diane McKelvey, DVM, DABVP (Feline Practice) Aberdeen Veterinary Hospital, Kamloops, British Columbia
- Elizabeth O’Brien, DVM, DABVP (Feline Practice) The Cat Clinic, Hamilton, Ontario
- Elizabeth Ruelle, DVM, DABVP (Feline Practice) Wild Rose Cat Clinic of Calgary, Calgary, Alberta
- Kelly St. Denis, MSC, DVM, DABVP (Feline Practice)
- Margie Scherk, DVM, DABVP (Feline Practice) catsINK, Vancouver, British Columbia
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