The information contained in this sticky is provided for educational purposes only and is not intended to replace veterinary advice. The intention of this sticky is to open doors to understanding about the specific medical condition or topic, allowing for educated and on-going discussion with your vet.

Diabetic Cat Care

Dental Disease 101

The American Veterinary Dental Society reports that 70% of cats show clinical signs of dental disease by the time they’re only three years old and by the time they've reached four years of age, 85% of cats have clinical signs of dental disease. We are led to believe by the pet food companies (the educators of our vets) that dry food will help keep a cat’s teeth clean and free from plaque. That is simply not the truth – think about that for a minute - how clean do your teeth feel after eating crackers or cookies?

There are many health issues which our FD cats seem to be prone to, and most if not all will affect the BG. If a previously well regulated cat suddenly becomes unregulated or a cat is hard to regulate then it is worth ruling out dental issues. The stress on the immune system due to infection and subsequent chronic pain can lead to higher numbers.

It is well known in human medicine (though less well-known in the veterinary world), periodontal disease causes increased insulin resistance and decreased glycemic control due to inflammation. Treating periodontal issues in our cats increases insulin sensitivity and glycemic control by decreasing inflammation. In addition, periodontal disease is such an important factor in diabetes that it is now listed as the sixth most common complication of diabetes in humans!

Dental disease in Diabetic Animals - Dr. Fraser Hale, DVM

An Education in Feline Dentistry - D.H. DeForge, VMD

Periodontal Disease

Periodontal disease is a progressive inflammation of the supporting structures around the teeth and include these signs;

-Bad breath
-Redness or bleeding along the gum line
-Drooling, which may be tinged with blood
-Difficulty chewing
-Pawing at the mouth
-Loose or missing teeth
-Facial swelling
-Nasal discharge
-Gum recession

How Is Periodontal Disease Diagnosed?

Your veterinarian can see signs of gingivitis and tartar build-up by examining your cat’s mouth. However, since most periodontal disease occurs beneath the gum line, the only way to truly assess your cat’s mouth is to perform an examination while your pet is under anesthesia. Your veterinarian will use a dental probe to measure any loss of attachment around each tooth and take dental radiographs (x-rays) to assess for bone loss, abscesses, and other problems.

What Causes Periodontal Disease?

Periodontal disease starts when bacteria form plaque on the teeth. Within days, minerals in the saliva bond with plaque to form tartar, a hard substance that adheres to the teeth. The bacteria work their way under the gums and cause gingivitis, which is an inflammation of the gums. Once under the gums, bacteria destroy the supporting tissue around the tooth, leading to tooth loss. Inflammation of the bone and tooth support structures is referred to as periodontitis. The combination of gingivitis and periodontitis is known as periodontal disease. Bacteria associated with dental disease can travel in the bloodstream to infect the heart, kidneys, and liver.

Untreated periodontal infections often lead to more serious health problems because of chronic pain and infection, and subsequent stress on the immune system. These untreated conditions can then lead to heart valve disease, kidney disease, and even diabetes and cancer, not to mention the significant discomfort associated with dental infections.

Treatment depends on the severity of the disease. If your cat has mild periodontal disease, consisting of gingivitis without any bone loss, a thorough dental cleaning that includes the area beneath the gums, followed by dental polishing, can help reverse the problem.

A dental cleaning may include the following:

-Removal of visible plaque and tartar from the teeth
-Elimination of plaque and tartar from under the gum
-Probing of dental sockets to assess dental disease
-Polishing to smooth enamel scratches that may attract bacteria
-Dental radiographs (x-rays) to evaluate problems below the gum line (usually how resorptive lesions are discovered)
-Application of fluoride or a dental sealer.
-Dental charting allows for monitoring progression of dental disease
-Inspection of the lips and tongue for growths, wounds, or other problems

If there has been a loss of the supporting structures around the teeth, this cannot be reversed. Your veterinarian may need to apply antibiotics beneath the gums and perform dental procedures, which may include tooth extraction.

When it comes to dental care, the most important issue is to remove the bacteria by cleaning the teeth (under general anesthesia) and addressing any infected tooth by removing it or doing root canal therapy. Some veterinarians will require the use of antibiotics first in an attempt to kill the bacteria and some won't. Generally, even if abx are successful to kill bacterial prior to a dental surgery, it will only be a temporary fix.

RESORPTIVE LESIONS - a relatively new phenomenon in cats

Dr. Hodgkins - DVM Posted - 10/24/2006

Resorptive lesions are a relatively new phenomenon in cats, roughly coinciding with the rise of the indoor keeping of cats with all of the poor lifestyle practices that cats are now subjected to (dry cat food with ACID sprayed on the outside of carb-filled kibble that coats the teeth of the cat, over vaccination, etc.). Dry cat food does not keep cats' teeth and gums healthy, period, I don't care what the folks driving around in luxury cars paid for by dry cat food sales say. These lesions are gum line cavities peculiar to the cat. They are painful and extraction of teeth with these is usually justified. I cannot imagine leaving a cat with cavity-filled teeth alone rather than getting the teeth, with their exposed roots, out of the mouth, along with a thorough cleaning to help prevent additional lesions.

Tooth Resorptions in Cats, Dr. Fraser Hale, DVM

Feline Oral Resorptive Lesions - Toothvet.ca

Tooth Resorption in Cats: Feline Oral resorptive Lesions (FORLs)

Feline odontoclastic resorptive lesion - WikiPedia

Evaluation of calciotropic hormones in cats with odontoclastic resorptive lesions - AVMA/PubMed

Rapid Screening Technique for Feline Odontoclastic Resorptive Lesions - Wiley abstract

If your cat has been booked in for a dental there are a number of things you will need to think about:

Before proceeding with dental surgery, please see the following stickies for more information;

Before and After Surgery, Anesthesia, Pain Medications.

BEFORE AND AFTER THE DENTAL PROCEDURE

Food will need to be withheld from at least 6 to 8 hours prior to the visit to the vet. Most vets will tell you they require a 12 hour fast, but Dr. H has repeatedly stated 12 hours is too long. The reason behind fasting is to avoid “aspiration” (aka vomiting) which can be caused by anesthetics used.

If your vet has indicated that they will test your cat’s BG levels and administer glucose if they feel that BG are too low, you may wish to consider giving only a half scale dose or even withholding insulin altogether on the shot prior to the dental procedure. Many vets do not know that most non-FD cats’ BG rests between 2.8 to 3.8/50 to 70. Lack of insulin for one shot is easily treated once the cat is back home and able to eat on its own – the effects of dextrose based fluids administered by a vet during surgery will take a lot longer to recover from.

Many vets will not release a cat after a dental procedure until the cat is standing, has urinated, and is eating on its own. If your vet is likely to feed your cat then take along a tin of low carb food for them to feed and ask that a sign be taped to your cat’s cage specifying ONLY the food brought with your cat is to be fed.

When you bring your cat home, it is likely they will still feel the effects of anaesthesia, and may likely be quite wobbly on their feet. It is a good idea to make temporary accommodation so that your cat is prevented from injuries – moving their bed from the couch to the floor, blocking stairways, and keeping them off furniture will help prevent falls. Moving the litter box closer temporarily, and/or using a litter box with lower sides might also be helpful. Sometimes elevating feeding dishes, using flat plates rather than bowls will make it easier for your cat to eat as many owners find their cats’ mouths (and tongues) are still frozen from the procedure hours later. Sometimes hand feeding your cat is called for.

When starting to feed your cat after it has returned home from a dental procedure, it is recommended to feed in small amounts to help prevent vomiting.

Your vet should send you home with pain medications as well as very clear instructions on proper administration. It is important to have a clear understanding of what signs to look for should your cat have an adverse reaction to any particular pain medications used.

From Dr. Hodgkins’ forum posts:

Dr. H - DVM Posted - 10/24/2006

Vets who advise against dentals because of a cat’s age are just plain WRONG. This is more of the "why spend money on THIS cat? You can get another for just a few dollars at the pound" mentality that still pervades my profession! Some vets just don't get that many of their clients want THAT cat, not just A cat!!!! They also don't want to invest in the education and equipment to do geriatric anesthesia safely. This is really bad medical advice, as a matter of fact; there is nothing medical at all about the advice NOT to keep an older cat's mouth healthy. Imagine dentists making such recommendations for humans!!!!!!!

More from Dr.H - DVM Posted - 05/11/2007

Owner 1: My cat is having a dental next Wednesday and will likely have at least 2 teeth extracted. The poor guy is going to be out of teeth to extract soon. He normally eats homemade raw, but is that ok in the days following extractions where there are open wounds in his mouth? I don't want him to get an infection...

Owner 2: Personally, I think its fine. I feed raw post-extractions - and I feed raw to one cat who has open sores in her mouth (stomatitis) and I've never had a problem.

Are they sending him home with antibiotics? My vet usually prescribes antibiotics and pain meds if there are extractions.

Dr. H: No change in diet should be necessary. I agree about the antibiotics and pain meds…

INFORMATION FROM OTHER SOURCES

Dispelling Common Dental Myths

by Fraser Hale, DVM, FAVD, DAVDC

MYTH #1: Dogs and cats do not feel dental pain the way people do. They have a higher pain threshold.

Basis for Myth: Serious dental problems are commonly detected as incidental findings during routine physical examinations. When questioned by the veterinarian or technician, the owners may say that they have observed no indication that the animal is uncomfortable. The pet still eats and may even still chew on hard toys.

The Truth: In 1991, a series of articles on pain perception and management in animals was published; these articles indicated that dogs and cats have the same pain thresholds and tolerances as humans.^1-4 In other words, dogs and cats feel pain in the same way and to the same degree as humans do. They react and withdraw and defend at the same level of stimulation and have the same physiologic reactions to pain as humans. This was true of all categories of pain assessed, including dental pain. Although these references are now somewhat dated, they provided the foundation upon which today's pain management principles were established. Few would deny that the veterinary profession has experienced a dramatic change of attitude with respect to pain over the past decade. Today, entire volumes as well as chapters in numerous texts are dedicated to pain management.

So why is it that with so much more awareness of pain perception in companion animals, dental or oral pain so frequently goes unnoticed? The explanation for this apparent paradox is actually very logical. If a dog has a sore tooth, that is one problem. If the dog allows that sore tooth to keep it from eating, the dog now has two problems: a sore tooth and hunger. From the dog's perspective, it is better to eat with a sore tooth than to go hungry. Also, dogs live in an outwardly cooperative but internally competitive hierarchical society. A pack member seen as weak or distressed will lose social status and may even be cast out as a liability to the pack or killed outright. Therefore, nature has taught dogs to mask their pain. Finally, the pet has no way of knowing that by complaining, it can increase its chances of getting relief. Therefore, the pet has no reason to complain and a few reasons to hide its pain. An animal that stops eating because of dental or oral pain is in extreme pain and has basically lost the will to live.

Cats are not socially cooperative, so the same argument does not hold true for them. However, being small animals, they are subject to predation. Therefore, they too are not inclined to advertise their distress.

Under further questioning, many owners often agree that their pet has been showing signs that could be related to dental disease. There may be a history of a change in preference toward softer food and toys; chewing on one side (as evidenced by excess calculus accumulation on the disused side); a general decrease in vigour; drooling; pawing or rubbing at the mouth; decreased enthusiasm for food and toys; ocular discharge; and sneezing.

Time and again, owners have stated that a pet was showing no signs of pain previously, but once the problem was treated, they realized that the pet had been in pain. The improvement in attitude and well-being after successful dental treatment is often very dramatic.

Recommendation: Since dogs and cats do not readily show signs of pain, it is important for technicians to thoroughly question owners during the routine physical examination to determine if subtle changes have occurred in the pet's behaviour. These signs may be indications of a dental problem. By explaining that dental conditions that are painful to humans are just as painful to pets, technicians can encourage pet owners to care for their pet's teeth.

MYTH #2: For minor tartar accumulations and mild gingivitis, simple scaling without anesthetic is often sufficient.

Basis for Myth: This myth likely grew from client concerns about the risks involved with general anesthesia. In order to offer some level of dental care at a theoretical reduced risk, some veterinarians offer a "standing dental," which is simply scraping the easily accessible portion of the crowns of the teeth while the patient is awake. Groomers and breeders have also been known to offer this service. When finished, the visible portions of the teeth look clean to the naked eye and the animal's breath may be less offensive. This, coupled with a much lower fee and no anaesthetic risk, tends to satisfy the client.

The Truth: Proper dental care requires general anaesthesia with a properly fitted, cuffed endotracheal tube. For dental treatment to be therapeutically beneficial, all calculus and plaque must be removed supra-gingivally and, more importantly, sub-gingivally. All periodontal pockets should be probed and charted before root planing (either with or without flap surgery). All exposed tooth surfaces must be polished after scaling to remove residual plaque and create a smooth tooth surface that is easier to keep clean. Other concerns, such as oral and gingival masses, fractured and worn teeth, and orthodontic problems, should be investigated and charted and either treated by the veterinarian or referred to a specialist.

In the standing dental, only the buccal surfaces of the crowns are scaled. This procedure does not allow probing and cleaning below the gum line, between teeth, or on the tongue and palate side of the teeth. This procedure cannot be justified because it is not possible to polish the teeth of conscious patients, nor is it possible to conduct a thorough oral and dental examination unless the patient is under anesthesia. Therefore, subtle problems are left undetected and untreated until they become serious, obvious problems that are usually much more difficult to treat. In a standing dental, the airways are not protected; therefore, the patient could aspirate a chunk of calculus, resulting in serious respiratory disease. Standing dentals also leave plaque and calculus in places where the owner cannot see; therefore, the owner is given a false sense of security that the pet's mouth is healthy. Standing dentals scratch the enamel surface but do not allow polishing, so the tooth is left even more plaque retentive than before. These procedures can often lead to damage to the gingiva if the animal moves while there is a sharp instrument in its mouth.

Recommendation: Standing dentals are more harmful than helpful; therefore, veterinary professionals should refuse to offer this service. In addition, this procedure is bad for the profession because it undermines the efforts of professionals who offer proper dental care.

MYTH #3: If a broken tooth does not seem to be bothering the patient, there is no need to treat it.

Basis for Myth: Often, patients present with a fractured or worn tooth in which the pulp has been exposed, but the owner states categorically that it is not bothering the animal. The owner points out that the dog or cat is still eating and chewing normally and shows no signs of discomfort (see Myth #1). On physical examination, there is often no evidence of oral swelling or gingival inflammation.

The Truth: If a tooth has been broken or worn to allow pulp exposure, it is a problem that must be treated. A tooth with an open pulp chamber becomes a direct pathway for bacteria to enter the periodontal ligament space around the root tip. This will result in a chronic inflammatory response (periapical periodontitis) at the root tip. Not only will this cause a chronic, dull ache, but it can also act as a potential source of septicaemia. Occasionally, periapical inflammation will fenestrate through the alveolar bone and allow the infection to spread to the surrounding tissues. This is true of infraorbital swelling (with or without drainage) associated with fourth upper premolar fractures. However, few endodontically diseased teeth will provide such an obvious indication for treatment. Most periapical lesions will remain encased in bone or fistulate to a less obvious site (nasal passages or oral cavity).

Recommendation: If a fractured or worn tooth with pulp exposure is noticed on the initial physical examination or is mentioned by the owner, the technician should bring the situation to the attention of the veterinarian immediately. He or she should then recommend either extraction or root canal treatment. It is imperative to treat these conditions. Teeth with crowns that are discoloured (i.e., grey, tan, purplish pink) almost always have pulp necrosis and should also receive endodontic treatment or extraction.

In patients with facial swelling or a draining fistula associated with an infected tooth, antibiotics will often bring temporary relief, but the problem will recur after the medication is discontinued. The veterinarian may prescribe antibiotics for a few days preoperatively, but antibiotics should never be offered as a substitute for surgical treatment.

If the owners wish to save the animal's tooth through root canal treatment, this should be performed as soon as possible by a veterinarian who is trained and equipped to perform this advanced procedure. If the condition is left untreated for long enough, the inflammatory process can destroy the root tip, making standard root canal treatment impossible.

MYTH #4: A fractured primary (deciduous) tooth requires no treatment because it will fall out on its own.

Basis for Myth: It is true that primary teeth are supposed to fall out on their own when dogs and cats are between 4 and 6 months of age. Many practitioners are hesitant to anesthetize young animals and so would rather just let nature deal with the fractured tooth.

The Truth: The most commonly fractured primary teeth in puppies, for example, are the long, thin canine teeth. Typically, these teeth do not exfoliate until the puppy is about 5-½ months of age.¹³ If the tooth is broken at 12 weeks of age, the puppy would have to live with this painful condition unnecessarily for 2-½ months. During that time, bacteria can enter the open pulp chamber and infect and kill the pulp. Infection can then extend beyond the root tip into the space around the root to infect the bone and the tissues involved in producing the adult teeth. The inflammation can cause permanent deformities to the developing teeth and may even inhibit the physiologic absorption of the primary tooth root. Therefore, the dead, infected tooth may not fall out when it should.

Recommendation: Veterinary technicians should notify the veterinarian immediately if they detect damage to the crown of a primary tooth that involves pulp exposure. The veterinarian will recommend that the tooth be carefully and completely removed as soon as possible.

MYTH #5: Old animals are not suitable candidates for dental treatment.

Basis for Myth: Because older patients generally have higher anesthetic risks, some veterinarians feel the benefits of treatment do not justify the risks.

The Truth: In the past, anesthetic risks were higher and the level of dental treatment available lower; therefore, the risks might not have been justified. But dental procedures and anesthetics have changed! Although some patients are too systemically ill to be candidates for general anesthesia, no animal should be denied the benefits of proper dental care merely because it is old. As veterinary professionals, our job is to prevent and relieve pain in animals. Many dental conditions are not only sources of chronic pain but also potentially serious sources of chronic septicaemia. These situations have a significant negative impact on both the quality and quantity of life for the patient. With our present resources for preoperative diagnostics, intraoperative risk management, and postoperative care, the risk of losing a patient to a general anesthetic has been greatly reduced (there is always a risk with any procedure in any patient). Also, the level of dental care available, particularly through referrals to specialists, has increased incredibly over the past 10 years. It is now safe to say that the risk to the quality and quantity of life associated with dental treatment is lower than the risk associated with dental neglect.

Recommendation: If your veterinarian mentions that a patient is too old for a needed dental procedure, encourage him or her to refer the patient to a specialist.

MYTH #6: Periodontal disease is an inevitable consequence of aging.

Basis for Myth: Many geriatric dogs and cats have severe periodontal disease.

The Truth: Periodontal disease is largely preventable. Through the judicious use of abrasive foods and toys (nothing too hard), appropriate home care dental programs, and timely professional oral hygiene procedures, it is possible for dogs and cats to live a long life and lose no teeth to periodontal disease. With the exception of patients with feline external odontoclastic resorptive lesions and those with immune-mediated and systemic conditions (e.g., lymphocytic-plasmacytic gingivostomatitisa), any time a dog or cat loses a tooth to periodontal disease, it can be seen as a failure on our part to establish an appropriate preventive program.

Recommendation: Although the importance of proper dental care can be discussed during senior wellness visits, technicians should ideally educate clients about proper oral hygiene for their pets during the animal's first visit to the clinic as well as during subsequent visits. There are numerous ways for technicians to educate clients about preventive dentistry. Educational materials (e.g., flyers, pamphlets) can be created and distributed to clients during each visit. By demonstrating proper tooth brushing, technicians can ensure that pets will receive proper care at home. Technicians can also give clients hand-outs on proper brushing technique. Helping clients establish home care dental programs and encouraging routine professional cleanings can be instrumental in helping to prevent periodontal disease.

MYTH #7: Referral dentists are too expensive. My clients will not be interested in a referral.

Basis for Myth: Because dental specialists often use diagnostic and treatment modalities that are not commonly used by referring veterinarians, and because they are more likely to find and treat subtle but significant problems, it might be true that the average visit to a dental specialist costs more than the average dental procedure performed at the general practitioner's facility.

The Truth: Because dental specialists have years of training and experience and have invested in a great deal of equipment and materials, they are uniquely equipped not only to recognize, diagnose, and treat obvious problems but also to detect more subtle dental diseases that are common in companion animals. By performing a thorough evaluation and carefully planning and implementing treatment, the overall benefit to the patient can be maximized. The result may be higher cost, certainly. More importantly, though, there is enhanced value to both the patient and the client.

Recommendation: By explaining the importance of dental care to pet owners, technicians can influence their decision to take their pets to a veterinary dental specialist. At a staff meeting, technicians can discuss the importance of dental care and what options are available to clients. Perhaps the veterinarian would consider offering dental referrals routinely, even for patients that appear to have simple problems.

MYTH #8: Referring a case is an admission of inadequacy and can have a negative monetary impact on the practice.

Basis for Myth: Most veterinarians are used to performing minor or major miracles on a daily basis. Clients have come to expect this from veterinarians; therefore, veterinarians are hesitant to disappoint them by admitting that there are problems that are beyond their personal capabilities.

The Truth: No veterinarian is an expert in all areas of veterinary medicine. There is too much information to absorb for any one person to be extremely knowledgeable in all areas. The pet-owning public is becoming increasingly aware of this fact. Referrals are common in other areas of daily life (e.g., lawyers, human dentists, physicians, contractors, financial service providers), and it is only logical that they be used in veterinary medicine as well.

Becoming specialized in dentistry requires a great deal of education. Human dentists spend 4 years of full-time study to meet qualifications. Veterinary dentists (diplomats of the American or European Veterinary Dental College) devote many hundreds of hours over at least 5 years to become specialized. By comparison, undergraduates at most veterinary schools receive a few hours of lecture devoted to dentistry. Becoming an expert in dentistry requires both time and experience. In some cases, clients contact specialists on their own because they want their pets to receive specialized care. Clients who seek their own referrals may harbor some resentment toward their practitioners for not suggesting the referral themselves. Sometimes when patients are referred, clients ask why their practitioners did not refer them sooner.

PREVENTION

Regular, at-home dental care combined with periodic veterinary dental cleanings, is the best way to prevent periodontal disease and keep your cat’s mouth healthy. The best time to start dental care is when your cat is a kitten. Just like having their nails clipped, starting a dental care program when cats are young is usually better accepted and well-tolerated.

An informative video is offered by Cornell Vet with step by step instructions on how to brush your pet’s teeth video, and recommends that pet owners brush their pets' teeth every day, or at least several times a week. The cost of a toothbrush and pet toothpaste is far less than treatments for dental disease, which can include x-rays, teeth cleaning and tooth extraction. You can use a child’s toothbrush or purchase a finger brush from your veterinarian. Human toothpastes should be avoided because they contain substances that pets shouldn’t swallow in large quantities. Check the labels carefully when it comes to “pet toothpaste” as many contain ingredients which are not suitable for FD cats. A raw chicken wing, trimmed and split is the best “natural” toothbrush for cats. Of course, the younger the cat, and the sooner you start, the easier it is to get them accustomed to having their mouths and teeth cleaned!