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VetInfo Digest October 2002

Table of Contents:

Routine Dental Care
Fractured Teeth
Feline Odontoclastic Resorption Lesions
Gingivitis and Periodontal Disease
West Nile Virus
New Domain Names vetinfo4cats.com and vetinfo4dogs.com

This Month's Note:
The odds are very high that the following statements are true about one or more of your pets:
1) Your dog or cat needs to have its teeth cleaned.
It is estimated that 80% of dogs and cats have tartar accumulation and either gingivitis or periodontal disease sufficient to warrant teeth cleaning at any time. If your dog or cat is older than six years of age the odds are high they have dental disease that is uncomfortable and in some cases outright painful.
2) Your cat has an odontoclastic resorption lesion (FORL) affecting one or more teeth.
This is a defect in which the enamel and tooth structure disintegrates over time and is thought to be painful by most veterinary dental specialists. It is estimated that 25% or more of cats have this disorder or will develop it during their lifetime.
When all veterinarians were "horse doctors" dental disease was a major part of the veterinarian's job, because a horse doesn't perform well when its mouth hurts. As many veterinarians shifted to pet centered medicine, dental disease was largely ignored, because it didn't really affect a pet's "performance" and it was easily overlooked. For the last twenty years or so dental disease has slowly regained prominance in veterinary practices. Routine dental care should now be a regular part of health care for most pets.

Routine Dental Care
Veterinary clients and even veterinarians often seem reluctant to accept routine dental care as part of the health maintenance of pets. This is surprising given the great gains in educating people about the importance of taking care of their own teeth. It is less surprising when the difficulty in providing effective dental care is factored in, though.
Most of us find it difficult to brush our dog's teeth or our cat's teeth and thorough dental scaling and polishing requires anesthesia, making it more challenging than routine teeth cleaning in people. These difficulties make us want to downplay the importance of dental care for overall health, so that ignoring it doesn't seem so bad. It is better to admit that the care is desirable and also to admit that it is difficult to provide and then to set about finding the best way to provide acceptable care with as little risk as possible.
Anesthesia is the single most important limiting factor in providing effective routine dental scaling and polishing services for pets. This is one of the greater paradoxes in veterinary medicine --- how do you compare the rare but grave risk of death during an anesthetic procedure with the long term health benefits of good quality dental care? On the one hand, there is the risk of sudden death. On the other hand there is constant discomfort, sometimes acute pain and clear indications that most patients will live longer and healthier lives if they have routine dental care.
Twenty years or so ago, there was a doctor's strike that I read about in the newspaper. The death rate for the affected community dropped sharply during the week or so of the strike. No one seriously argued that giving up medical services long term was a good idea, but the decrease in the death rate was intriguing. Why did it occur? Primarily because surgical procedures involving some risk were not being performed --- so a number of patients lived through that week who would have died during surgery. On the other hand, the long term prognosis for these patients was not improved by the lack of surgery. If there had been no opportunity for that care over the long run, more of these people would have suffered shorter life spans.
Veterinary dentistry is something like this. There is no question that there is a short term risk when a pet is anesthetized. There is also no question that maintaining the health of teeth and gums, as well as dealing with existing disease issues, makes pets much more comfortable and that it prolongs the life of most pets when routine dental care is provided. Obviously, many people chose to take the risk of anesthesia to provide a better life for themselves so it seems reasonable to me to accept this same risk in order to provide a better life for our pets.
It would be a lot easier to help pets with dental care if it was possible to teach them to brush their own teeth. Tooth brushing is the mainstay of preventative dental care in humans and that should be true for pets, as well. However, many pets are extremely reluctant to allow their teeth to be brushed and most pet owners find setting the time aside to do it and upsetting their pet to get it done to be too much of an obstacle to keep up routine dental care. For this reason, there are a number of companies working on alternative means of providing the same effect as brushing.
Dental health care foods are available from several companies. For the most part these foods do seem to help some, although our clinical experience suggests that is more likely to be true for dogs than for cats. When dogs do not have other health problems requiring a specialized diet this an option to consider. Based on our patients we feel that the cat tartar control diets and treats do not work well enough to recommend them for everyone, although we do have one or two cats in the practice that do seem to benefit from these products. If your pet has a strong tendency to develop tartar and no medical problems requiring dietary control then it may be helpful to use a tartar control diet or tartar control treats.
A number of companies make toys that are meant to help control tartar accumulation. Some of these are effective for individual pets but only rawhide chews, such as Chew-eze (tm) treats have actually been shown to significantly reduce tartar in well controlled studies.
Some dogs do have problems with vomiting rawhide chews and lots of dogs won't chew on them. I have heard of intestinal obstructions associated with rawhide chews that are swallowed whole at meetings but I have not actually encountered this problem in our practice. One of my dogs seems to benefit from chewing on a Kong (tm) toy frequently and there are probably other toys that will work for a few dogs.
Real bones can be very helpful in eliminating tartar. Unfortunately, they also seem to cause enamel fractures of the upper premolar teeth very frequently, as well. I have not been able to decide whether the fracture risk is greater than the tartar control benefits in my patients. When bone chewing (or rock chewing) does damage to the teeth the typical problem is that a slab of the enamel on the side of the largest tooth in the rear of the mouth breaks off. If the slab is deep enough to allow exposure of the internal tooth structures the tooth will decay and eventually a root infection occurs. If the enamel slab is more superficial tartar sticks to the tooth much better than it did before the enamel fracture and this increases the risk of periodontal disease. On the other hand, overall tartar accumulation is often dramatically less in dogs who chew bones. At this time I can not decide whether the risk of tooth fracture exceeds the risk of tartar accumulation so I just tell my clients to feed bones if they want to and what to watch for if they do. There may be swelling below the eye on the affected side if a tooth root abscess does occur. Often, there will be a lump that will have some drainage of pus.
Brushing a pet's teeth is often easier than you might think. If your pet will allow you to rub a finger over the base of the teeth and the edge of the gums, there is a very good chance that you would also be able to brush the teeth. We advise clients to start tooth brushing using their finger and a small amount of flavored tooth paste or a baking soda paste. If the pet tolerates this well, then try using a gauze pad or a finger tooth brush. Your vet can supply the finger tooth brush but these are also available in pets stores and even in regular stores as they are sometimes used as an aid in human infant tooth care.
Tooth brushes are made for both dogs and cats and they probably are the best method of cleaning the teeth. I have had at least fifty or more clients tell me they are using human tooth paste with no problems, so I suspect that it is OK to use human toothpaste. However, veterinary dentists strongly recommend using a toothpaste made for pets and most of these are flavored with pets in mind, possibly making them more acceptable to pets. If you graduate to a toothbrush and can brush your pet's teeth daily you will be making a significant impact on your pet's dental health.
Most of my clients do not brush their pet's teeth on a regular basis. I have a large group of clients who brush their pet's teeth on an irregular basis and I think they do some good even though they are not consistent. I also have a larger group of clients who would never consider brushing their pet's teeth. I sympathize with this because I fall into the category of people who are inconsistent in tooth brushing, primarily because one of my dogs is very reluctant to allow the procedure and fighting with her over the procedure gets old quickly.
Even when teeth can be brushed daily, veterinary dental experts recommend yearly scaling and polishing of the teeth, along with dental X-rays if there is any indication for them, including an interval of longer than a year or two since the last dental X-rays were taken. When it is not possible to brush a pet's teeth it may be necessary to consider scaling the teeth more frequently than once a year. We had a Cavalier King Charles Spaniel whose teeth were brushed regularly and who still required scaling and polishing of his teeth at least twice a year to keep tartar accumulation under control. If it has been more than year since your dog's teeth were cleaned, it is highly likely that tartar accumulation sufficient to warrant scaling and polishing is already present.
Cats are a little different story, in my personal opinion. It is important that you recognize that the next paragraph is purely my opinion and that every veterinary dental health expert that I know of disagrees with this opinion. However, I feel that it is possible to maintain reasonably good dental health in cats by hand scaling the teeth, usually without anesthesia, on a regular basis. We attempt to hand scale teeth using regular dental scalers during every examination, unless no tartar is present.
Surprisingly, most cats will allow us to do this even though it is slightly uncomfortable for them. I honestly believe that this is helpful in preventing the development of gingivitis and periodontal disease in cats and I think that it may reduce the incidence of feline odontoclastic resorption lesions (discussed later) -- but I can not prove this as we have done no objective studies in our practice.
The reason that I believe that hand scaling is effective in cats is that most of the tartar accumulation in cats occurs on the surface of the upper premolar teeth on the side of the tooth that faces outward. This is much different than dogs, in which tartar accumulation is more common on the inside tooth surfaces and tends to affect many more teeth. In addition, a cat's mouth is shallower and it is possible to work on the rear teeth with good accessibility, which also is not true in dogs. Obviously, there are cats who develop tartar on other teeth or who develop tartar in less accessible areas, and these cats require dental scaling and polishing under anesthesia, just as dogs do. However, for most cats, regular removal of the tartar accumulation on the upper premolars seems to provide benefits based on our clinical experience. It is still very important to consider scaling and polishing under anesthesia when indicated, especially when it is obvious that tartar accumulation on the inner surface of the teeth is present.
I have been really surprised by client's reactions to dental care suggestions over the years. One of my better clients, who had spent several thousand dollars on surgery for her pets, laughed when I suggested dental scaling and polishing for her dog's teeth. "Doc, that's just going too far." On the other hand, I have several clients who won't provide basic care for other problems but do an excellent job of brushing their pet's teeth and will pay for more advanced dental care, probably because they are seeing the changes on a regular basis.
We choose to own pets. We choose to provide the food and medical care that helps them lead longer lives. We should also choose to provide them with dental care that keeps them comfortable and as pain free as possible.

Broken teeth
We see broken teeth on a regular basis in both dogs and cats. Both dogs and cats tend to break their canine teeth when they are fighting and playing. Dogs have a tendency to break their upper premolars when they chew on very hard objects. This is especially true for the fourth upper premolar, which is the very wide tooth in the upper jaw. Many of the broken teeth that we see in cats are due to degeneration of the tooth due to feline odontoclastic resorption lesions, rather than an injury to the tooth. This is something that has to be considered when broken teeth are found in cats, unless the cause of the break is obvious.
The four canine teeth are the large "fangs" that both dogs and cats possess. These teeth were meant for grasping and holding prey and for self defense. These duties tend to predispose them to injury, though. Canine teeth break off during fighting in cats fairly often and are injured during play, especially catching activities, in dogs. Be extremely careful about using a baseball bat or tennis racquet to hit balls for dogs to chase, as these activities are among the leading causes of trauma to teeth and also cause eye injuries commonly to dogs in our practice.
In cats, even a small tip fracture of a canine tooth can expose the pulp of the tooth, causing the tooth to be susceptible to root infections and death. Dogs can often break the tip of the tooth and sometimes even more of the tooth without injuring the deeper tooth structures. It is best to have X-rays taken of broken canine teeth to try to determine if there is damage to the internal structures of the tooth in all cases, but this is especially true for cats. If initial X-rays show that there is no involvement of the pulp in the fracture it is a still a good idea to consider follow-up X-rays in six months or so, just to be sure.
If the fracture does involve the dentin layer or pulp of the tooth it is best to have a veterinary dentist who is skilled in endodontics examine the tooth. At the present time there are many options available for saving damaged teeth and there are good reasons to try to save the teeth. From an economic standpoint it is often less extensive, or at least not more expensive, to have a canine tooth repaired than to have it extracted. These are difficult teeth to remove without causing complications and consequently it is expensive to have them removed.
Teeth can be capped and kept in a vital state by this procedure in many instances. It is possible to perform root canal therapy if the tooth is damaged badly enough that it can't be kept alive but is still strong enough to be preserved. Doing this can prevent future abscesses or bone loss associated with retention of dead teeth. General practitioners sometimes fail to point out that these procedures are available through dental specialists, so if your pet has a broken tooth don't forget to ask about repair as an alternative to extraction.
When dogs chew on hard objects they often fracture off just the enamel, or a combination of enamel and underlying dentin, but may not damage the tooth pulp. This occasionally happens in cats but it is rare for the underlying structures not to be involved when cats chip or fracture the enamel layer of the teeth. It is possible to use glass isomers or other restoration compounds to repair the enamel fractures but these are not nearly as strong as the original tooth structure and it is hard to get the dog to give up on the behaviors that lead to these fractures. So most of the time we recommend leaving these teeth alone if the pulp cavity is unaffected and watching carefully for signs of irritation at the gum line or swelling of the face above the tooth and removing them if these problems occur. If the pulp cavity is affected by the original fracture it is probably best to go ahead and remove the teeth at the time of the injury or to consider root canal therapy to try to preserve the remaining tooth structure but still head off complications.
When teeth other than the canine teeth or the big premolars are broken, there is usually an underlying disease process damaging the teeth or a traumatic event caused the fracture. It is important to look for damage to surrounding teeth and to underlying bone whenever a traumatic tooth fracture occurs.
Saving a tooth, rather than extracting it, can be a better choice in some cases. Dogs with heavy lips may constantly find their lips caught between the gum line and the remaining canine tooth if one of their canine teeth must be removed. If both canine teeth have to be removed on one side, and sometimes when both lower canine teeth are removed, the pet's tongue may slip out of the mouth constantly. Excessive drooling sometimes occurs. Pain when chewing on bones or toys can be a problem if there is a large gap between the teeth. In rare instances removal of teeth can lead to bone resorption in the surrounding areas that causes facial deformities.
Veterinarians are often quick to jump to extraction as the best method of dealing with fractured teeth but if you are inclined to attempt to preserve the tooth, or teeth, do not forget that there are veterinary dental specialists now and many general practitioners are becoming better and better at endodontic or even orthodontic procedures necessary to save teeth. This is a time when getting a second opinion, if you wish to, is very reasonable. Dogs and cats do well after extractions and long term complications from missing teeth are not especially common, but they do sometimes occur.

Feline odontoclastic resorption lesions
Even though this disease is called feline odontoclastic resorption (lesions) there are occasional reports of similar problems in dogs. One author has reported a rate of odontoclastic resorption lesions above 10% in his canine patients. So don't rule out finding this disease in your dog, even though it is still referred to as a feline disease in most texts.
Odontoclasts are cells in the teeth whose job it is to dissolve the mineral tooth structure when it is necessary to do so. They play a major role in the resorption of baby teeth. They really don't have a major role in the maintenance of adult teeth. For some reason, in cats with FORLs the odontoclast are activated and begin to dissolve the dentin and enamel of the teeth. This can happen in any portion of the tooth but it most commonly starts in the tooth roots.
At the present time we do not know what causes this problem in cats. There have been many theories proposed but none have been proven.
Odontoclastic lesions often cause inflammation of the gums over the area that is affected. So a classic appearance for this lesion would be a tooth that looks normal except that there is a bubble of gum tissue that covers a small portion of the tooth. In advanced cases the gum may not be able to creep over the damaged area enough to cover it and so it is possible to see that the tooth is eroding away with careful examination. When the tooth roots are sufficiently damaged the surrounding bone reacts to the disease process and tries to form bridges to the tooth root structure. This process is referred to as ankylosing.
With almost 100% uniformity, veterinary dental specialists recommend removal of teeth affected by FORLs, or repair of the defects (if caught early) with the understanding that the disease process will continue and the tooth will eventually require removal. Their feeling is that with exposure of the pulp of the tooth there must be pain. This is a reasonable assumption. However, removal of these teeth is not easy as they tend to break apart at the damaged sites. In addition, ankylosing of the tooth roots can make them extremely difficult to remove. Due to these complications, most general practitioners aren't too enthusiastic about removing teeth with FORLs.
We tend to follow a middle of the road course on FORLs. We remove these teeth when we have a client who is motivated to do so, when we believe that there has to be pain associated with the lesion (more severe lesions) and when we have to anesthetize a cat for another non-life threatening procedure, making it reasonable to do this while the cat is anesthetized anyway. We hold off on tooth removal when it seems likely that the tooth will disappear on its own soon (when we find these very late), when the pet owner is convinced they are not painful and when the cost of tooth removal endangers the rest of the cat's care.
It can be hard to assess whether pain is present or not, since cats can't talk and often hide pain well. Signs of oral pain include head shaking, tremoring jaw movements when eating, drinking or grooming, refusing to eat, avoiding cold water, dropping food while eating, odd tongue movements and weight loss. Dental disease may cause sneezing, coughing, bad breath, and drooling whether pain is present or not.
FORLs can affect any tooth and are commonly missed when they affect canine teeth and small premolars, as the gum inflammation sometimes completely covers the tooth when smaller teeth are affected and canine teeth are often affected on the back of the tooth where the smaller lesions escape detection. If a FORL lesion is found in a tooth on one side of the mouth the tooth in the same position on the opposite side should be examined as it is not uncommon for FORL lesions to occur in the tooth in the same location on each side of the mouth.
There is some controversy over exactly how to treat FORLs. A clean extraction of the entire tooth is generally recognized as best but almost all veterinarians will concede that this is not an achievable goal in some patients with weak teeth or ankylosed roots. For this reason, two alternative procedures have been advocated in cats for dealing with these teeth when removal seems necessary.
One method of avoiding difficult extraction procedures involves using a high speed dental burr to drill out the tooth, a procedure sometimes referred to as root "atomization". There are some risks associated with this procedure as it is not too difficult to lose track of the depth of the drill and damage underlying nerves or even to create an opening into the sinuses. Veterinary dental specialists are divided in their support of this method.
The second approach is to use a dental burr to remove the entire crown of the tooth and enough of the root to allow the gums to be sutured closed over the remaining root. This procedure is referred to as crown amputation. The root will usually go on and dissolve without causing problems, as long as there was no evidence of infection or a preexisting immune system disease such as feline leukemia or feline immuodeficiency virus present. If this procedure is chosen, it is necessary to check carefully for signs of inflammation on a regular basis for several months. It is estimated that this procedure will be successful about 90% of the time, with complications occurring in the retained roots, requiring a procedure to remove them, in the remaining cats.
Cats are not always easy patients to perform dental examinations on. Despite this, your vet should be examining your cat's teeth carefully during routine examinations, especially yearly physicals. This is important enough that we will consider using sedatives or anesthetics to accomplish the examination in resistant cats. When odontoclastic resorption lesions are found a plan should be made for monitoring them if extraction does not seem immediately necessary or for removal of affected teeth.

Gingivitis and Periodontal Disease
More than half of dogs and cats over the age of 3 to 5 years have periodontal disease and most dogs and cats over one or two years of age have gingivitis.
The gingiva is the margin of the gum that contacts the tooth and it should be a very thin but movable flap of tissue that helps to protect the tooth socket from collecting foreign material such as hair or food. Gingivitis is present when there is gingival inflammation, which usually shows up as redness or even red rings at the gum line around the teeth. Tartar begins to accumulate on the teeth as gingivitis becomes more severe but X-rays of the tooth root structure are normal.
Periodontal disease occurs when gingivitis becomes severe enough that there are pockets of pus or areas in which the gums have retracted from the tooth. The gums may bleed easily when touched. As periodontal disease progresses the bone around the tooth and the ligaments holding the tooth in place weaken and the tooth becomes loose. Eventually the tooth will fall out on its own, if not extracted, or a root abscess will occur, necessitating extraction.

In our practice most dogs and cats have visible gingivitis by the time they are two to three years of age and many cats and small dogs have gingivitis before they are a year of age. By the time dogs and cats are middle aged almost all of them have tartar accumulation sufficient to cause early periodontal disease. It is unusual for a dog or cat to make it to older age without developing periodontal disease, although we do have some patients who have clean healthy teeth throughout their lifespan.
Gingivitis can be treated successfully in most dogs and cats simply by scaling and polishing the teeth, especially if it is possible for the pet's owner to brush its teeth after the dental cleaning. Once periodontal disease is present, it is necessary to scale and polish the teeth, to consider the use of fluoride, chlorhexidine or doxycycline topical therapy and oral antibiotics may be necessary, as well. As periodontal disease progresses it may be necessary to consider surgical treatment for deep pockets around the teeth and regular dental scaling and polishing at close intervals until the disease process can be stopped. In severe periodontal disease it is often necessary to remove teeth due to severe root exposure and weakness of the structures supporting the teeth. In some cases aggressive therapy can still preserve teeth at this stage but it is much better to start regular dental care early and to avoid getting to this stage.
If tooth preservation is of great importance this should be discussed with your vet prior to dental scaling procedures, as many teeth are removed easily enough that it is almost routine practice to remove them during routine dental scaling as it is often easier than scaling and polishing them. This may be a problem for pets who are shown in breed shows, working dogs and in some cases simply because of the importance of the tooth involved to the appearance and functionality of the pet. When tooth preservation is important to a client we almost always offer referral to a veterinary dentist as they can sometimes help with tooth stabilizing procedures that we don't offer. You have to initiate the conversation about saving questionable teeth and about seeking referral to a veterinary dental specialist, so don't hesitate to do this if it is important to you.
It is sometimes shocking to clients when we suggest coming to our office for dental scaling and polishing procedures every 3 to 6 months to try to preserve teeth. However, many of our clients brush their own teeth several times a day and have dental cleanings at their own dentist twice a year -- and this is the routine recommendation. Dogs and cats really do need dental care, too. At the present time most veterinary dental experts recommend having a pet's teeth scaled and polished once a year, starting at 1 to 1.5 years of age. Most veterinarians wait until problems appear before recommending teeth cleaning but it is probably better to start taking care of teeth earlier and trying to avoid the development of problems instead of waiting until they are present and treating them.

Foreign Objects in the Mouth
Dogs are very prone to biting down hard on an object and breaking it into several pieces, one of which fits perfectly between their upper teeth. In our practice sticks and bones often end up bridged between the upper teeth. This causes a lot of distress and some dogs will frantically paw at their mouth or rub their face repeatedly on the wall or floor. When this type of behavior is observed it is a good idea to open your dog's mouth and shine a light on the upper palate to look for a stick, bone or other foreign object caught between the teeth. Some dogs tolerate the discomfort associated with this problem without complaint but then develop really horrible breath as the roof of their mouth and the roots of the affected teeth become infected. Really bad oral odors should also prompt a search for a foreign body trapped in the mouth.
In both dogs and cats we sometimes see splinters of bone or other sharp objects that have wedged between teeth. We have even seen this happen when dogs chewed on crab shells or lobster shells and small pieces of the shell become entrapped between teeth. Often these seem to be very painful or irritating to the pet and some will paw frantically at the side of their mouth, or rub it constantly until the piece of foreign material is removed. These foreign bodies can be extremely difficult to see, especially bone splinters, as they often match the color of the teeth closely. Once in a while we can only find these objects when we do our examination using a magnification. Usually it is quite easy to resolve this problem, although many pets will require short term anesthesia before they will allow an object to be grasped with forceps in their mouth for removal.

West Nile Virus
This isn't a dental issue, but I get questions in my office almost every day about West Nile virus. This is partly due to the prevalence of mosquitos in my practice area but I am sure that it is a concern in many other areas of the country, as well.
Dogs and cats have been documented to have titers against this virus, so we know that exposure to it is occurring. This makes sense. Two dogs (one reported this month) and at least two cats have been suspected to have encephalitis as the result of this virus, although it is unclear in all cases if West Nile virus was responsible for the symptoms that the dog or cat were displaying. If these cases are real, they can be compared to the human infection rate, in which approximately 500 humans are suspected to have had this disease and at least 30 people have died. Horses seem to have an infection rate a little higher than humans. The risk to dogs and cats appears to be very low in comparison with other species, so it is unlikely that a vaccine will be developed for dogs and cats unless more cases are confirmed. At the present time mosquito avoidance is still the best preventative measure and also helps to decrease the possibility of other more common diseases such as heartworm disease.

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These are the domain names that we are currently providing information in. We have divided up the dog and cat sections of our site and purchased domain names for each of them, as this is easier for us and saves a small amount of money per month in data transmission and storage fees. We will continue to coordinate all of these through the vetinfo.com site and will provide the subscriber area through this domain name, but you might want to bookmark the specific sites if you prefer cats or prefer dogs and don't want to bother sorting through mixed information.
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The opinions expressed in this newsletter are those of Michael Richards, DVM., author. Thanks for Your Support!

Copyright 2002, TierCom, Inc.
This page was last edited 06/21/04

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