Periodontal Disease in Dogs - with Dr. Judi Stella

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Transcription

Cat Matloub [0:03] We’re super excited to kick things off with Judi leading the conversation and discussion today around periodontal disease, which is something near and dear to Judi’s heart. It’s something that should be near and dear to all of our hearts, as she educates even Monica and I about. This is a bit of a postponement of a webinar. We ran out of time last week or the week before, so we’re excited to give this the full treatment, full time. We also will have a very exciting announcement at the end of the webinar that relates to the topic. Judi, I’ll let you take it away. Do you have the tech figured out? You don’t need any help doing that? Sharing screens? 

Dr. Judi Stella [0:53] Did I get it right this time? 

Cat Matloub [0:56] You’ve done it!

Dr. Judi Stella [0:59] Welcome, everyone! Thanks for joining us today. As Cat said, this is a topic that’s near and dear to my heart. I got into this a little bit when I was postdoc and working for the USDA. I worked in a research lab, and we were out in the field looking, working with large-scale breeders with USDA. What we found was that there was a lot of periodontal disease, and we were constantly talking to breeders about it, telling them they needed to do something about it. But nobody was actually giving them any good advice. We didn’t know what to tell them to do because there just wasn’t any really good ways to monitor it and effective preventative care that you could do on a large-scale that would help decrease the risk of disease. I did a couple of studies with a friend of mine that was postdoc at the time, and we are going to talk about a little bit of that research, as well as just periodontal disease in general. 

[2:05] Why do we think this is such a big deal? Periodontal disease is a significant health and welfare problem for all dogs. Pet dogs, breeding dogs—it doesn’t really matter. It is consistently one of the top two or three preventative health diseases that dogs present to the regular veterinarians every time when they go in for their yearly exam. It’s always in the top two or three diseases that dogs have. More than 80% of dogs, by the time they are two years of age, have some degree of periodontal disease, so that can be anywhere from gingivitis all the way up to tooth loss and really severe disease. There are local effects in the mouth, so: bleeding gums, tooth loss, and the pain associated with that. But the other important aspect of this is that these dogs are also at increased risk for heart disease, liver disease, and kidney disease as well. There’s these systemic effects. Importantly to dog breeders, it may increase the risk of negative pregnancy outcomes, so premature birth, low birth weight, increased infant mortality, and smaller litters. We know that this is true in humans, rats, and non-human primates. We have not done these studies. These need to be epidemiologic studies, because obviously we don’t want to induce periodontal disease or not treat it and then see what happens to pregnant dogs; that would be unethical. These have yet to be done, but what I can tell you is that it’s unlikely that it’s skipped dogs, if it’s in rodents and many other species. Anecdotally, I’ve heard from breeders that have large facilities that when they’ve started preventative care in their colonies or in their facilities, that they have actually had better litter size. That’s anecdotally; we don’t really have good data on that, but it’s likely to be true. 

[3:58] What is periodontal disease? It is basically an infection and inflammation of the gums, bone, and tissues that surround and support the teeth. There is this reported association of gingivitis with nutritional deficiencies, so if you have a nutritional deficiency of these vitamins (A, C, D, E, and some of the B vitamins), there may be increased risk for gingivitis. Basically, it’s an overgrowth of predominantly gram (-) anaerobic bacteria. So this bacteria lives in the mouth. It’s pretty normal. But you get an overgrowth of it if it’s underneath the gums (so between the gums and the teeth) and then that’s what causes the gingivitis. If left untreated, it will progress to more significant and severe disease. Again, it’s associated with this increased risk of systemic disease, like I was talking about liver disease, kidney disease, and heart disease. That’s because of the release of these inflammatory cells and the byproduct. So the bacteria gets in their blood system and then travels to the organs that filter the blood, which would be the kidneys and liver, and then also you get some inflammation of the heart. That’s what endocarditis is. Nephritis and glomerulonephritis are kidney diseases. And then hepatitis is a liver disease. It can be pretty significant and then obviously have a negative impact on dogs. 

[5:34] Most of the periodontal disease, like I said, progresses underneath the gums. It attacks the tissues and the bones that are supporting the teeth. When you look at a dog’s mouth, what you’ll see is this is a clean, healthy mouth. These teeth have no calculus on them. The tissue, the gums, are a nice, light pink, and they don’t look inflamed at all. When you start to see gingivitis, you’ll see this redness and inflammation, and you’ll also start to see a little bit of that calculus right on the gum line there. At this stage, it’s reversible. If you treat this and clean the dog’s teeth, get rid of that infection, it doesn’t actually progress any further. If you leave it untreated, what happens is you’ll start to get more build-up of calculus. You’ll start to get some gingival recession, so the gums start to recede a little bit. As it progresses, you’ll see more of that. More plaque and bacteria, more plaque and calculus, accumulating on teeth. Eventually, what you’ll wind up with is the teeth will just fall out. There’ll be puss and blood associated with it. It becomes pretty severe. That’s painful. The dogs stop eating. These pictures (these X-rays underneath) show that this is a healthy mouth. You can see where the bone is all the way up around the roots of the teeth. As this progresses, you start to lose bone. These black spaces—that’s bone loss. As it progresses, you can see where the roots of these teeth are super shallow. They’re just loose and they’ll fall out. Obviously, at that point, it’s irreversible. You can’t build back that bone. Once that bone loss starts to happen, you can’t grow it back. If you catch it early enough, at stage two, the dogs don’t necessarily lose their teeth. They just have a little bit of bone loss, and you can halt the progression at that point. 

[7:26] It’s important to remember that most of this disease happens underneath the gum line. It’s sort of like an iceberg. You can see the tip of the iceberg, but you can’t really tell what’s happening underneath. The only thing that we can do to find out what’s going on underneath is by doing X-rays. We’ll talk about that a little bit more later. 

[7:44] We know that there are certain risk factors associated with periodontal disease. Smaller breed dogs are more at-risk than giant breeds or larger-breed dogs in general; that doesn’t always hold true. Greyhounds are a larger-breed dog, and they are notorious for having periodontal disease. It’s starting at a very young age. We don’t really know why. May be true of other sighthounds as well. We have so many more Greyhounds that are seen in veterinary clinics; we have that data. There’s probably some smaller-breed dogs that don’t have as severe disease as either, but in general, that holds true. Obviously, the older the dog gets, the greater risk they have. This holds true for people as well. The older you get, no matter what you do, you start to have some tooth loss and periodontal disease. We also think that Brachycephalic dogs are at greater risk. The data is not really great here. We don’t have a ton of data about this, but we think that the dogs that have these short faces—their teeth are crowded. It just makes more opportunity for bacteria and food and plaque and everything to build up in there. 

[9:01] Like I said, we did do some of these studies. The first thing we wanted to do was develop a tool. We wanted to develop a visual tool that you could use. Like I was saying, most of the disease is happening underneath the gum line. You can’t see it. How do we monitor it, unless we just take our dogs in all the time and X-ray them (which isn’t practical)? In certain situations—large kennels, shelter situations—there are people that have dogs that are at risk for being under anesthesia. We want to have a better way of monitoring this (while the dogs are awake). And then we can intervene when it’s necessary. We wanted a validating tool. Basically, we took the picture of the different mouths with the gingival recession and the plaque build-up, and what we did was we made this scoring tool. We looked at dogs that were awake before they went in to have a dental cleaning. They were already scheduled to go in for a dental cleaning. We just wanted to look at their teeth and score them and see how well our score correlated what was going on underneath the gum line, when the veterinarian went in and cleaned everything and took X-rays. What we found was it actually was pretty predictive. Where we had problems and where it wasn’t as accurate was that we would often overestimate the extent of the periodontal disease, rather than underestimate it. So for a visual assessment tool like this, that’s actually good. It just means that we would intervene a little bit sooner, rather than too late. That was actually good. We decided that we would take this out and use this in the field. We recruited kennels in Indiana and Illinois. These breeders were large-breed kennels. They were USDA-licensed. They were all in good standing. No write-ups or citations or anything like that. They were relatively good kennels. We went in and did this visual assessment on these dogs, and then we also asked the caretakers what kind of preventative care they were doing. So, what diet do you feed? Treats? Any kind of chew items and other types of preventative care? 

[11:27] We wound up recruiting 445 dogs in total. We wanted to make sure we had a big sample size. We had 42 breeds represented at 27 facilities. Again, we wanted to make sure that this was going to be generalizable to general populations. What we found was that the estimate for periodontal disease—all grades, so Grade 1 is gingivitis (that reversible stage) all the way to Grade 4 (which is severe; the dogs have no teeth left)—about 86% of the dogs had some degree of periodontal disease. These dogs were relatively young, so it wasn’t that it was the age, really. They were breeding dogs, so typically they were less than five or six years of age. Pretty significant disease, but also pretty consistent with what’s been reported for pet dogs in the literature. On the upside, on the good side, was that a lot of it was Grade 1, which was gingivitis, based on our visual assessment. Grade 2 isn’t too severe either. About 14% of the dogs had severe periodontal disease. That was good, but there’s still too many dogs with periodontal disease. 

[12:43] When we looked at the association with breed size, we did some statistics here. We used our giant-breed dogs as the comparison group, so they were our reference group, since they are reported to have the least amount of periodontal disease, the least amount of risk. We compared all the other size groups. We found that our little guys (less than 10 pounds) were about 2.7x more likely (or at greater risk) of getting periodontal disease. These guys, these little guys (11-35 pounds) were 1.5x, and then we found our large-breed dogs were 2.9x. We had some Brachycephalic dogs in there. We did not find any association with Brachycephalic skull shape, but we also had Boxers and Mastiffs and larger-breed dogs in that group, as well as French Bulldogs and Bulldogs. There might’ve been a little bit of confounding there. We did have dogs to pull that out. The risk may have been elevated because we had a lot of Boxers in there. But, basically, it kind of went along with what we thought. The larger the dog, the lower the risk. 

[14:00] And then we also looked at some of the preventative care that the breeders were using to see if any of them were better than others, so that we could actually make some good recommendations for what will and won’t work. Chlorhexidine is an antibacterial that you can put in water, or that’s how they were doing it. They put it in the water. The idea is that the dogs will drink this antiseptic and that it’ll clear up the infection in their mouth. What we found is that it didn’t really work at all. There was no effect of that treatment at all on the severity of disease. We did find that providing chew items (breeders that would just buy bones; often, they were raw bones—they would have an agreement with the local butcher, and they would steam the bones or slow-cook them and then give them to the dogs to chew on) was a really good option, because it provided enrichment for the dogs. It gave them something to do that they enjoyed doing, and it did look like it had a protective effect. Having something to chew on decreased the risk of periodontal disease. And then I don’t know how many of you are familiar with non-professional dental scaling, but it takes a sharp scrapers, and you scrape the tartar off the outside of the teeth. What we found—that was pretty commonly done. Instead of having the animals go under anesthesia and having a full cleaning, a lot of the breeders use that as an option. That actually increased the risk. It’s likely because it scrapes the enamel off the teeth as well, and that leaves a rough surface, which is more likely to attract bad calculus to build up. It’ll just build up quicker on that rough surface. And also because it doesn’t get underneath the gum line, right? All that infection that is underneath the gum line is still there. The teeth look a little bit better, but it doesn’t actually help with the disease at all. 

[16:09] Professional cleaning is the standard of care. That’s basically what we found in our research. You can do some things at home, but it doesn’t really negate or replace professional cleaning. It’s still the standard of care. What happens is you take your dog to the veterinarian. They’ll do a visual, oral exam while the dog is awake, very similar to what we did when we were scoring and trying to validate our tool. They put the dog generally under anesthesia. They’ll use local blocks when needed. They’ll do a complete oral exam, and that typically is full-mouth dental radiograph. They’ll take pictures of every tooth in the dog’s mouth. And then they’ll also probe any broken teeth. They’ll probe the roots. They’ll look for dead teeth abscesses. They can measure the amount of gingival recession using a tool that’s called a probe. They’ll do all of that on each and every tooth. They’ll do a cleaning, so they’ll do an ultrasonic cleaning very similar to what we do when we go into the dentist. You know those waterpik kind of things that get all underneath the gum line and all the tartar inside and outside (so on the outside surface of the teeth and the inside). Then, they’ll do a professional scaling and polishing. Sometimes they’ll put a fluoride treatment on. It leaves it all nice and clean and smooth. That is still the standard of care. Obviously, we don’t want to put our dogs under anesthesia. I don’t know about any of you, but it always makes me nervous, even though I’ve been in veterinary medicine for years. I know it’s really safe. We all get nervous about putting our dogs under anesthesia. We want to make sure that we do this as infrequently as possible. Typically what veterinarians recommend is starting at the age of two (smaller dogs and some breeds that are predisposed, you may have to start sooner), annually, you should have your dog go under for a complete exam and cleaning. 

[18:22] Preventative care at home may actually either delay that (so we can start those dental cleanings later in life) or decrease the frequency (so we may be able to extend it from every 12 months to every 18-24 months, at least until they're older). Ideally, we would do our dental cleanings and then also pair that with preventative care at home. Cat and Monica get mad at me when I tell them this, but brushing your dog’s teeth is the absolute best at-home care. It’s most effective. We know it. In study after study, we know that it’s the most effective means of plaque control. It’s super low compliance of both dogs and humans. The tricky part is that you have to do it at least five times a week for it to be effective. Recent study that I just found this week actually (it was just published in 2020)—it was in a Swedish population—but just to show you how poorly the compliance is: they recorded that less than 4% of owners brush their dog’s teeth daily. About 47% of owners say they never brush their dog’s teeth, and 36% of the owners said they wouldn’t even consider brushing their dog’s teeth. 

Cat Matloub [19:37] Judi, maybe you should deliver this information with less judgement! The numbers are astounding, but not surprising, given… FIVE times a week?! 

Dr. Judi Stella [19:55] I know. 

Cat Matloub [20:00] You’ve got to come up with something. You’ve got to talk to the scientists for one of those quick fixes. We’ve got to get one. 

Dr. Judi Stella [20:05] I’m only reporting the numbers! I don’t want anyone to feel guilty about it, because no one does it, right? And, on top of that, this paper said that 31% of the veterinarians didn’t even recommend it to their clients, and it is the gold standard for preventive care at home. I don’t think it’s ever going to get adopted. I’ve been recommending this for as long as I can remember, and we just can’t do it. I would still recommend it and urge everybody to brush the dog’s teeth. You don’t even have to use toothpaste, because it’s literally just the action of the toothbrush on their teeth. That friction is what helps. They do like the taste of toothpaste. They will get used to it. I do do it with my dogs because I’ve been in this way too long. (Plus, I have a Greyhound that has really bad teeth.) I do do it, and they do get used to it. It’s just one of those things. When I brush my teeth at night, I brush the dog’s teeth. But I only have two dogs, so I can imagine if you had eight or ten, it would be difficult. Some of these other things that we can do at home: there are these antiseptic rinses (which is chlorhexidine that I was telling you about that’s used in the water that had no effect). I don’t know that it’s much better at home. What we do know is that if you are going to use this chlorhexidine, there is no known bacterial resistance, so you can use it every day, and there’s not going to be bacterial resistance. It has been shown to decrease gingivitis if you apply it consistently. The gels are the best, and you just apply it to the gum line. You just have to, every day, apply it to the gum line, and it will decrease gingivitis. The negative parts of it are that it tastes bad. Some of those gels—they do have some flavor enhancers, but the dogs typically don’t like it. Again, it should be applied to the teeth and gingiva. We don’t know if it’s safe for pregnant/lactating bitches. I cannot find any information about it that anyone’s done (safety tests) on that. I would caution you. I don’t know that I would use it or recommend it in pregnant/lactating bitches. I would talk to your veterinarians about that. In high concentrations, it can cause burns. It’s actually caustic, so it’ll burn the gingiva and their throats as well, but if you buy a commercially available product, that’s unlikely to happen. 

There’s these other things we can do. The diets are good. They’ve been shown to decrease plaque and calculus. Again, the caveat is that it has to be the main diet. The way the kibble is shaped and the way that it’s formulated, it will scrape the plaque off of the teeth. Again, it’s that abrasive action. They are larger kibbles, so it increases chewing and, again, will increase the efficacy of that abrasive action. It’s not effective at the gingival margin—right where the teeth and the gums meet, it doesn’t get right there. It’ll only scrape the plaque off the lower parts of the teeth. Again, it’s not AAFCO approved for all life stages. I would not feed this as a main diet in pregnancy or gestation. It could be cost prohibitive. It’s a prescription diet, and they can be pretty expensive. Another option is to use it as treats, so you’ll get a little bit of the benefit, and it’s not the main diet. You can try that. Little, small-breed dogs—they do have a small-breed version of it that’s a little bit smaller kibbles. Those smaller dogs (those toy breeds)—they still don’t really like chewing it. It’s a big kibble for them, and they tend not to like it. But if you can get it in them, it’s a good option. 

Chew items, I would argue, are probably the best. They have been proven to decrease plaque and calculus. It’s that abrasive action. The benefit to these is that the dogs actually like them. It’s enriching. They have something to chew on. The negatives are that it may not be effective right at that gingival margin, and you have to be careful because you can get tooth fractures. I have a dog that’s a heavy chewer, and she fractured one of her teeth. They call them slab fractures. They just slice off the outside part of their teeth. That’s a rough area, so you have to be really careful with those teeth after that happens. Dogs do like chewing on them. There’s also some new products that have come out that look like bones, but they’ve got ridges and things in them. You can put the enzymatic toothpaste on those to encourage the dogs to chew on those. They’re an option that I would recommend. One thing to look for when you’re looking at any of these rinses or dental diets or chew bones (especially CET chews)—things that are created for dental care—make sure that they are VOHC approved. That is the Veterinary Oral Health Council. They have a little seal of approval on the products that they’ve tested. They will tell you. You can go to their website, which is on here. You can see how effective they are and how often you have to use them. Some things need to be every day. Some things need to be 5x a week or 3x a week. They’ll tell you what that is and what research has been done on them. I would encourage everyone to check that out. 

One last thing that you might want to consider (it is a little bit costly) is called TDC. It’s these little gel caps. You can either feed them straight to the dogs, or you can (if you’re using them for dental purposes) twist off the little end and apply the gel right on the dog’s gum line. It’s really good at reducing inflammation that’s associated with gingivitis. I can tell you that one of the veterinary dentists that I work with actually recommended these a lot. He told me about them, so I was like, Alright, I’ll try it with my Greyhound who has really bad gingivitis, like, to the point where, when I brush his teeth, his gums bleed. So I’m up for anything! It really does work if you do it every day. It really, really reduces the inflammation. You can see it, and it’s great. Like I said, it’s a little bit expensive, so if you don’t mind the cost. Additionally, TDC is a fatty acid supplement, so it’s safe for dogs, but they also market it as having these additional health benefits. It’s really good for joints, muscles, performance recovery for agility dogs and things, and it’s really good for their skin and coat. I think it’s a beneficial product. There’s some science behind it. It’s just something to consider. 

[27:16] One thing that you can do to minimize the amount of times our dogs go under anesthesia and just make sure that we know when it’s time to do it and that they definitely need it—this is a test strip that many veterinarians use now. When you go in for your annual exam, it’s just a little pad, and you just rub it on the dog’s gums. And then you can compare it to the chart, and it’ll tell you how severe the dental disease is, how much microbial action there is. Basically what it’s measuring is thiol. Thiol is a byproduct of the bacteria. The microbes that are present produce this in large quantities. It’s just a metabolic product. It’s a proxy measure for the amount of bacteria in the dog’s mouth. It’ll give you a little bit more of an idea. In addition to the visual assessment, it’ll give you a little more of an idea of how bad the infection is. It might help you decide when you want to go in for a full cleaning. 

[28:40] Just a note on this anesthesia-free dentistry, which is that non-professional hand-scaling that I was talking about earlier: the American Veterinary Dental College really has a position statement out there saying not to do this. Again, it’s those reasons that I stated. It doesn’t clean the gum line, and it won’t prevent periodontal disease. In fact, you can’t identify many conditions that are going on, so it’s not good at all in replacement of a full cleaning. It leaves that rough surface, so it’s the perfect environment for bacteria and calculus and plaque to build up again. Additionally, from a welfare perspective, it’s really painful and stressful for the dogs! These tools are really sharp. I don’t know if you can see this, but this is a really sharp dental tool. What you do is you just scrape the tartar off the teeth and just chunk it off. It causes their gums to bleed, and they really don’t like it. If your dog doesn’t like having its teeth brushed, it’s certainly not going to like sitting there for that to happen. It causes their gums to bleed. If they have loose teeth and things like that, it can be really painful for them. I would encourage you to avoid that. 

[30:04] Like I said, we did all of this research and wanted to make it easily available for anybody. All this research and all these studies that we did are in these three little documents in user-friendly format. It summarizes all that information. One of them has the scale on there, so if you wanted to monitor your dog’s dental health at home, it’s something that you could do. We were recommending for the dogs in the breeding facilities that—when they would pull the dogs out once week to weigh them or groom them or just look at them—they would just look in their mouths real quick and try to score their teeth and keep a diary of it, so they could see when things were starting to progress, and then they could get the dental cleanings. Again, all these dental products (the different at-home care) is also in one of these. Those are free downloads on the USDA website. 

[31:07] And that’s all I have! But this is our big announcement! July is officially Good Dog’s Dental Health Month, and so in order to celebrate this kickoff of dental health and this webinar that we’re doing, we want to help everybody add some dental preventive care to their program. We are giving $10 off of a professional dental cleaning or any VOHC-approved preventative care product for the entire month of July. If you want to take part in that or participate, we will be sending out an email later today or this week, right, Cat?

Cat Matloub [31:50] I think we’ll be getting that email out tomorrow, if I’m not wrong, so you guys get a sneak peak of it. We’re really excited. We did Good Dog’s month of Canine Genetic Health in May, and now we’re excited to do this. It’ll be kind of the kickoff where we try to take a different topic related to health each month and give you guys an extra benefit, an extra incentive to highlight some of these important things. It’s hard to keep up because there’s so many things to be mindful of, so we’re excited to have Judi steering us clear. Honestly, I’ve got to get my dog’s teeth cleaned. Round 2? Yeah, okay. Speaking of, we have a question from Cynthia. (Hi, Cynthia!) “I have Wheaten Terriers who have an issue with tartar build-up, so I use a finger brush with petrodex advanced enzymatic, which has a very appealing flavor. I noticed that sorbitol has first ingredient, which scares me. Should I be worried if I use 3-5x a week?” It’s actually a good question, so it’s much used. “I also use bones and chew toys in conjunction with this ‘brushing.’ Thank you for your input.”

Dr. Judi Stella [33:09] You know what, I’ll have to look into that. I know it’s xylitol that’s the one that’s really bad for dogs. I don’t know if sorbitol is. I will check into that for you and get back to you for sure. Like I said, the other thing I would do is get on that VOHC-approved website and use those. I’ve used petrodex before. Isn’t it that brown jelly stuff? It does have a nice flavor to it. C.E.T. is another enzymatic toothpaste—really good. That’s the one I typically use. But there’s a lot of them. I’ll check into the sorbitol because I don’t know. I would assume that if it’s being marketed that way, that it should be safe, that it would be safe—but we shouldn’t assume, I guess. 

Cat Matloub [34:06] Cynthia shared—I’m going to share it with everybody. “The 7 best dog toothpastes of 2020” from Spruce Pets. I’d be curious to hear your thoughts on this, too. Thank you so much for sending that, Cynthia. I’m going to message it back to everybody, courtesy of Cynthia! Awesome. I need to take a look at that, too. Do we have any other questions? Any questions for Judi, about the benefit, suggestions? This was wonderful, Judi. Honestly, also a reminder that I need to go to the dentist myself. 

Dr. Judi Stella [34:58] I know, me too. I take better care of their teeth than mine. 

Cat Matloub [35:03] Totally. Thank you guys so, so much for joining us as always. This was so fun. I’ll follow up over email with the recording. Take a look into those different kinds of toothpastes. Definitely, if you guys have any recommendations or tips or fun ways that you remember to brush your dog’s teeth and make that a part of the routine, this could be a really fun thing to share. Routines are the easiest ways to make habits that form, so it could be fun. If you’re not a member of our Breeder Center on Facebook or the Good Breeder group yet, dive in there. You guys can share some of what you learned today with some of your fellow Good Breeders. A lot of folks don’t know about how important it is for dogs. Thank you so, so much, Judi. This was wonderful and absolutely a critical topic—and one that more people should be talking about. Eddie said, “I set a reminder on Google Tasks to brush my dog’s teeth and cut their nails.” That is so smart. You know what we should really do, Judi. We should talk to Laura and figure out how to build optional Good Dog reminders. We’ll work on that. Thank you all so much!