True Prophylaxis

Overcoming barriers to preventive dentistry for cats & dogs
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One way or another, Nicholas Perrone and his wife have acquired 10 cats. Every night, he brushes each cat’s teeth.

It didn’t occur to Perrone to brush their teeth when he first acquired cats 30 years ago, but he agreed to a “dental” whenever his veterinarian said a cat needed the procedure. Then, one of his cats never recovered from anesthesia following a dental procedure, so he started brushing his cats’ teeth as a preventive measure.

Nicholas Perrone's cat on the exam table 
Nicholas Perrone brushes his cat Fifi’s teeth
Nicholas Perrone brushes his cat Fifi’s teeth at Blum Animal Hospital in Chicago. (​Photos by Katie Burns)

Now a client at Blum Animal Hospital in Chicago, Perrone believes that veterinary anesthesia today is very safe. He also believes that brushing his cats’ teeth has precluded the need for most dental procedures and saved him thousands of dollars.

The AVMA and other veterinary organizations celebrate National Pet Dental Health Month each February. Many cat and dog owners have been embracing preventive dental care for their pets in recent years, including home care and professional cleanings.

But there is a long list of barriers still to overcome in preventive dentistry for cats and dogs: a perception that care is unnecessary, the difficulty of home care, the cost of professional care, and an abiding fear of anesthesia. Anesthesia-free dentistry specifically is growing across the country and will be the focus of an article coming up in the Feb. 1 issue of JAVMA News.

The AVMA, American Animal Hospital Association, and American Veterinary Dental College each provide guidance for general practitioners on veterinary dentistry. Representatives of the organizations agree that preventive dentistry for cats and dogs has come a long way but still has a long way to go to truly meet its potential.

The basics

The AVMA policy “Veterinary Dentistry” focuses largely on defining all aspects of oral health care in animals as falling under the practice of veterinary medicine.

“Dentistry is a huge part of the practice of veterinary medicine,” said Dr. Christopher Gargamelli, a member of the AVMA Council on Veterinary Service, which oversees the policy. “That’s why having veterinarians directly involved and stating in multiple places in the policy that it’s the purview of veterinary medicine is very important.”

Also per the policy: “The veterinarian should perform an oral examination on all animals at least yearly and discuss preventative measures to keep a patient’s mouth healthy.”

Dr. Gargamelli noted that basic dental procedures for cats and dogs have come to include cleaning and radiography, both under anesthesia, with radiography becoming fairly routine over the past 10 years. Anesthesia and radiography add a lot of cost, of course. He said, “I think we struggle as a whole and as a profession about providing the highest level of care and at a cost that is affordable to owners, and I think it’s a struggle in everything that we do.”

Pet owners have a particular concern about anesthesia in older cats and dogs, Dr. Gargamelli observed. He believes veterinarians can allay that concern by communicating with clients about improvements in anesthetics and monitoring.

He also believes pet owners don’t understand the relationship between dental health and overall health—or how painful dental conditions can be. He said, “If we’re not explaining all of that to owners, then we are on some level doing them a disservice and doing the patient a disservice.”

At the request of AVMA members, the Association developed a brochure in 2015 to help educate pet owners about pet dental care. The brochure describes veterinary dentistry, causes and signs of dental problems, use of anesthesia, periodontal disease, and home care.

Dr. Gargamelli admits that he finds home care to be difficult. After his Chihuahua had a dental procedure, he and his wife decided to take turns brushing the dog’s teeth. Over six months, they brushed the dog’s teeth maybe six times. The AVMA dental brochure discusses toothbrushing as well as other options such as dental products, treats, and diets.

AAHA approach

“Veterinary medical dental care is an essential component of a preventive healthcare plan,” according to the 2013 AAHA Dental Care Guidelines for Dogs and Cats. “Quality dental care is necessary to provide optimum health and quality of life.”

Also per the guidelines: “Perform the anesthetized portion of the dental evaluation of charting, cleaning, and radiographs when abnormalities are seen on the awake exam (such as plaque or tartar at the free gingival surface of the maxillary canines or fourth premolars) or at least on an annual basis starting at 1 yr of age for cats and small- to medium-breed dogs and at 2 yr of age for large-breed dogs.”

Dr. Heather Loenser, AAHA veterinary adviser for public and professional affairs, said most cats and dogs will develop dental disease by the age of 3. She said, “That may cause systemic problems throughout the body, and that can be a hard link for pet owners to make.”

She said practices can take a team approach to dental cleanings, having veterinary technicians talk with clients about dental care and having staff ask clients to make appointments for cleanings.

Dr. Loenser said the mouth is an invisible place, and many pet owners are able to tolerate an inordinate amount of bad breath. She said, “The mouth doesn’t limp. It doesn’t do something really obvious. It doesn’t urinate outside the litter box.”

With signs of dental disease being so subtle, dental cleanings can be a hard sell. Dr. Loenser advocates taking photos over time to show changes to clients.

Dr. Loenser pointed out that the expense of cleanings results partly from steps to make anesthesia safe. She recommends that the practice team explain all those steps, from intravenous fluids to heat support.

The AAHA dental guidelines also cover home care. According to the guidelines: “Options include brushing and the use of dentifrices, oral rinses, gels and sprays, water additives, and dental diets and chews. Discourage any dental chew or device that does not bend or break easily (e.g., bones, cow/horse hooves, antlers, hard nylon products). The Veterinary Oral Health Council lists products that meet its preset standard for the retardation of plaque and calculus accumulation.”

A radiograph of a normal left maxillary canine tooth in a dog (Courtesy of Dr. Cindy Charlier)

Amazing changes

Dr. Curt Coffman of Arizona Veterinary Dental Specialists, an AVDC board member, believes that pet owners are increasingly aware of the importance of pet dental health. Veterinarians have made dentistry a bigger part of practice, for one thing. For another, manufacturers of pet products have seen a market for dental products.

“They’re making products or trying to come up with products that will provide hygiene, essentially prevent tartar and calculus buildup,” Dr. Coffman said. “Manufacturers are helping veterinarians educate their clients that dental health is important, and I think that’s been as big as anything in the last 10 years.”

Toothbrushing is still the best, he said, and many pet owners can do it. He knows owners of little dogs who even use a water pick or flossing tool between crowded incisors.

As for veterinary dentistry, Dr. Coffman thinks including cleanings and radiography in wellness packages is the future in making dental care more affordable for pet owners. He said, “I think there are ways to make it doable and reachable for most pet owners.”

Dr. Coffman has seen amazing changes in veterinary dentistry since he started in general practice 20 years ago and began specializing in dentistry 15 years ago. The referring veterinarians he works with perform radiography and chart the mouth, which he never did in general practice.

“The primary care veterinarians are more comfortable making a diagnosis, more comfortable offering cleaning and extractions,” he said. “I still think we’ve got an uphill battle of really getting the clients, again, the vast percentage of them, to commit before it’s a problem.”

Dr. Coffman suggested that a general practitioner can impress on a client that when cats or dogs reach age 2 or 3, “Let’s get them in and clean the teeth prophylactically. Let’s do a true hygiene procedure or ‘prophy’ on them and check for areas that could be a problem in the future.”

The next level

Dr. Cindy Charlier, an AVDC board member, owns Veterinary Dental Education Networking and Training in Illinois, which provides in-house consulting at general practices on oral health care and client education.

“By the time we as veterinarians make a recommendation for treatment and owners consent, we’re actually treating oral disease rather than doing anything to prevent it,” she said.

Dr. Charlier said general practitioners can offer a customized home care program based on what the owner can do and the pet will accept, along with regular dental procedures. In an ideal world, she would like patients to be under anesthesia when dental disease reaches stage 1 on the 0-4 scale.

“Then we can reverse the gingivitis process,” she said “Once we get to periodontal disease, we can’t make it go away. We have to control and slow the progression of the disease.”

Dr. Charlier said cats and dogs prone to oral disease, such as small-breed dogs, should be on a maintenance program to detect disease early.

“The issue with dogs and cats is they will never let owners know that their mouth hurts,” she said. “Dogs and cats don’t need all their teeth, but they need a pain-free mouth.”

Veterinarians can incorporate an oral examination into every physical examination and speak to every client about oral health care at every examination. Prevention is less expensive than treatment, Dr. Charlier said, and it lengthens intervals between procedures under anesthesia.

“All the barriers can be overcome, knocked down by client education,” she said. “Everyone needs to know what’s involved in the dental procedure, why we do it, the ramifications, so we can all speak the same language to clients.”

Blum Animal Hospital

Perrone, the owner of 10 cats, has done a remarkable job of desensitizing the cats to toothbrushing, said Dr. Natalie Marks, co-owner of AAHA-accredited Blum Animal Hospital in Chicago. For most of the hospital’s clients, their busy lives and pets’ resistance are barriers to dental care at home.

Like other practitioners, Dr. Marks thinks client education remains lacking on how dental disease affects the body and causes pain.

“We do full exams on every patient that walks in this hospital, no matter why they’re here, and an oral exam is included in that,” Dr. Marks said. “If there is dental disease, which, statistically speaking, is in most of our patients today, we make recommendations based on that patient. There are some of our patients that definitely benefit from twice-yearly procedures.”

Expense can be a barrier to dental procedures for some of the hospital’s clients, Dr. Marks said, but the team explains the costs and consequences of not performing the procedures. Most clients are comfortable with the hospital’s anesthetic protocols.

Dr. Natalie Marks, co-owner of Blum Animal Hospital, examines Fifi’s teeth
Dr. Marks examines Fifi’s teeth
Dr. Natalie Marks, co-owner of Blum Animal Hospital, examines Fifi’s teeth. (Photos by Katie Burns)

Overall, Dr. Marks sees a lot more interest in dentistry from clients. She said clients are becoming better educated “and also much more willing to invest time and care into keeping their pets’ oral health a priority, and it’s really nice to see.”

She thinks pet dental health has been improving with new dental products, new technology such as digital radiography, client education, and client willingness. Her team offers a variety of dental products.

Perrone got his first cat when he was 36. Then he went to four cats, and now he is up to 10. Along with toothbrushing, he used to give dental treats to his cats, but many of the cats just swallowed the treats.

The most recent additions to his family are a semiferal cat and her two kittens. The mother had to have 12 teeth pulled, and one kitten had to have eight teeth pulled.

For Perrone, all the effort is worthwhile. He says his cats have saved his health and his life.

“We had a few tragedies in the family that messed up my nerves,” he said. “And these cats just brought me back.”

Veterinary organizations celebrate National Pet Dental Health Month each February. The AVMA provides a veterinary toolkit to promote pet dental care at

Related JAVMA content:

Study identifies bacteria in feline plaque (Jan. 15, 2016)