Brook A. Niemiec
DVM, DAVDC, DEVDC, FAVD
Dr. Niemiec is chief of staff of Veterinary Dental Specialties & Oral Surgery, with 14 offices throughout the United States. He is a regular speaker on local, national, and international levels and was elected Clinical Instructor of the Year for the 2016 Western Veterinary Conference. He has authored many articles, chapters, and books and founded the veterinary dental telemedicine website vetdentalrad.com. Finally, he coordinates the San Diego Vet Dental Training Center, with 3 to 4 meetings per year covering basic and intermediate veterinary dentistry.Read Articles Written by Brook A. Niemiec
Dr. Stewart is a graduate of the Western College of Veterinary Medicine at the University of Saskatchewan. She was a member of the first Canadian graduating class in animal welfare at the University of British Columbia, and is passionate about furthering understanding of the veterinary applications of animal welfare. Dr. Stewart has authored several chapters on applied animal welfare, along with the welfare section of the WSAVA International Dental Guidelines. She is currently pursuing her board certification with the American College of Animal Welfare.Read Articles Written by Kymberley Stewart
The keys to treating and controlling periodontal disease in companion animals and humans are the same: removal and prevention of accumulated plaque.1 Bacterial plaque and its inflammatory byproducts are the instigating agents of periodontal disease in the form of gingivitis; however, the body’s individual response determines the progression of disease. (For a brief overview of the stages, clinical signs, and welfare aspects of periodontal disease, please see “Current Concepts in Periodontal Disease” in the January/February 2020 issue of Today’s Veterinary Practice.)
Depending on the degree of attachment loss (i.e., periodontal pockets and gingival recession) and client wishes and ability, plaque removal is accomplished through a combination of the following measures:2
- Routine professional dental cleaning
- Periodontal flap surgery
- Tooth extraction
- Home plaque control
The foundation of all periodontal care is a thorough professional dental cleaning. If careful oral examination finds no pathologic periodontal pockets (i.e., >3 mm in dogs, >1 mm in cats), minimal to no gingival recession, mild to no radiographic evidence of bone loss, and no mobile teeth, only a professional dental cleaning and home dental care are required. Unfortunately, most veterinary patients do not receive care until significant periodontal disease is present, and more extensive procedures are usually necessary.
Dental cleaning is a medical procedure that must be performed meticulously to provide a measurable benefit for the patient. General anesthesia is an essential aspect of professional cleaning, for both health and welfare reasons (BOX 1). Protocols (and terms) for dental cleaning vary,3 but the authors recommend the following steps:16
- A thorough preanesthesia examination and workup. This helps ensure safer anesthesia and creation of a reasonable estimate of time and cost.
- Proper anesthesia and monitoring. Dental procedures are typically lengthy and are often performed on older patients. The level of monitoring must be excellent to avoid mishaps.
- Chlorhexidine lavage. This decreases bacterial load not only for the patient but also for the practitioner, staff, and environment.
- Supragingival scaling. This is generally accomplished with an ultrasonic scaler.
- Subgingival scaling. This is by far the most important step. Unless the subgingival plaque is completely removed, minimal to no medical benefit has been achieved. This step can be performed with an ultrasonic scaler if a subgingival tip is used (FIGURE 1). However, if there is any attachment loss, hand scaling with a curette is recommended (see Closed Root Planing).
- Polishing. This smooths the tooth to retard future plaque attachment.
- Sulcal lavage with chlorhexidine, saline, or lactated Ringer’s solution. This has been shown to decrease bacterial counts as well as remove debris (e.g., calculus, prophy paste).
- Oral examination and charting. Periodontal probing (FIGURE 2) and exploring (FIGURE 3) should be performed on all surfaces of all teeth and marked on a high-quality dental chart (a copy of this chart is available for download at dogbeachvet.com). Probing and exploring are crucial. A simple visual examination will miss significant pathology (FIGURE 2).
- Dental radiography. Radiographs are mandatory for proper diagnosis and treatment. Full mouth dental radiographs are always recommended to allow complete assessment of all teeth;17,18 at a minimum, all pathology, no matter how minor, must be radiographed.
- Treatment planning and any additional therapy. Based on the visual, tactile, and radiographic findings, a treatment plan can be devised and the client contacted for consent. If it is determined that the procedure will be lengthy (i.e., >3 hours), staging the procedure is acceptable.
The handling required for thorough periodontal probing, scaling, and polishing all aspects of the teeth is intense and can cause significant patient pain and anxiety. To avoid compromising patient welfare, gentle, respectful patient handling techniques should be employed from start to finish (BOX 2), and analgesia should be used as needed. Minimizing fear and stress not only improves the patient’s experience and memory of the event, but also has been shown to decrease the amount of anesthetic needed and improve the postoperative rate of healing.26-28
Postoperative analgesia is also an important part of pain management. Reduction of pain and inflammation is harder when analgesia is not used before the inciting incident. Animals experiencing acute, unaddressed postoperative pain have extended healing times and higher physiologic stress levels than animals in which pain is adequately addressed.29
In teeth without mobility or furcation exposure class 2 or greater (BOX 3), periodontal pockets measuring 3 to 6 mm in dogs and 1 to 4 mm in cats can be effectively cleaned with closed root planing. All teeth with deeper pockets (FIGURE 4), furcation class 2 or 3 (FIGURE 5), or bone loss of >50% (FIGURE 6), or that are pathologically mobile require further therapy. It has been shown that it is impossible to effectively clean affected roots without direct visualization.30-33 Treatment options for these significantly diseased teeth include periodontal flap surgery and extraction.34 The patient can be referred for surgery, but these procedures can also be learned by general practitioners.
If periodontal surgery is elected, the owner must be aware that diligent postoperative homecare and regular rechecks are necessary.
Closed Root Planing
Closed root planing is a challenging technique and must be performed meticulously to effectively clean the teeth and allow reattachment of the gingival tissues. Ideally, it is accomplished using a combination of ultrasonic scaling with a subgingival tip (FIGURE 1) and hand scaling with a curette. The roots must be planed until they are clean and smooth. It is strongly recommended that the operator take a hands-on class to sharpen their skills in this critical technique.
After scaling, the authors recommend applying a perioceutic to improve gingival attachment.2 While a recent veterinary study refutes the effectiveness of these products,35 numerous other studies show that they decrease bacterial counts and improve attachment gains.30,36-38
Periodontal Flap Surgery
If the client wants to salvage a significantly diseased tooth, periodontal flap surgery can be performed.34,39 The flap allows visualization and cleaning of the infected areas to remove the infection and allow increased soft tissue attachment. Guided tissue regeneration can be considered in areas where bone may be regrown, such as the palatal surface of the maxillary canine and furcation exposure class 2 (especially for carnassial teeth), but sites should be carefully evaluated for appropriateness.
Extraction is typically the best therapy for nonstrategic, severely diseased teeth. While clients may find it extreme, it is the true cure for periodontal disease. With all other therapies, the infection will quickly recur, unless the client commits to regular homecare and professional cleanings.
Homecare is a crucial aspect of lifelong periodontal care. Plaque attaches to clean tooth surfaces within 24 hours of a dental cleaning,40,41 and in the absence of any other preventive dental care, bacterial counts return to pretreatment levels in just 1 week.42 Therefore, without homecare, gingival infection and inflammation quickly recur.43-47
Active homecare is most effective for the incisor and canine teeth, while passive homecare works best on carnassial (and surrounding) teeth.48 A combination of active and passive homecare is therefore ideal.49
Active homecare has long been deemed the “gold standard” of home dental care.50 It consistently decreases periodontal bacterial levels in dogs.51 The good news for clients is that the only required piece of equipment is a toothbrush. Numerous veterinary brushes are available, and even human soft-bristled (typically child’s) brushes can be used. There are also many varieties of veterinary toothpaste. While mechanical removal of plaque by the movement of the brush is the mainstay of plaque control,50 a recent study has shown that the paste also has beneficial effects.42
Available antimicrobial preparations improve plaque and gingivitis control compared with standard pastes when used during brushing (or on their own).52-54 Chlorhexidine has been shown in several studies to decrease gingivitis if applied consistently over time.55-57 Another effective oral antiseptic option is soluble zinc salts.58 A veterinary-labeled oral zinc ascorbate gel has been shown to decrease plaque and gingivitis.59 The fact that it is tasteless may increase its acceptance by the patient (especially cats).49
While toothbrushing is the simplest, least expensive, most effective way to decrease gingivitis and progression of periodontal disease, it is also the least likely to be performed by clients. Daily homecare is always recommended, as this frequency is necessary to stay ahead of plaque formation.40,60-62 Three days a week has been shown to be the minimum frequency for patients without active disease.63 Brushing once a week is insufficient for plaque control, but it is better than nothing.61
Best practices to help clients be most successful with toothbrushing revolve around client education, early intervention, and positive training and low-stress handling techniques. The younger the pet is, the more approachable it will be to this type of handling, so clients should be educated from day 1 on the importance of dental homecare and taught how to do it in a gentle and approachable manner, with lots of positive reinforcement training for the pet, as early in the pet’s life as possible. For example, at a first healthy puppy visit, showing clients how to gently introduce the pet to facial handling, oral manipulation and examination, and early toothbrushing habits (perhaps with just some toothpaste on a finger) without biting or resistance will help make a lifetime of oral homecare possible.
Passive homecare for periodontal disease is achieved with special diets, chews, and treats. Since it requires no effort by the client other than selecting the product, it is more likely to be regularly used. Compliance is especially important, since long-term consistency is a crucial aspect of home dental care.64 Sadly, daily toothbrushing with highly motivated pet owners is only around 50% after 6 months,65 and one study suggested that passive homecare is superior to active homecare simply because it is performed.66 However, it should not be inferred that passive care is actually more effective. The truth is that the average client is typically noncompliant with toothbrushing.
Some passive homecare methods are effective, but many are not. Practitioners should perform their own research using peer-reviewed published studies and the Veterinary Oral Health Council (VOHC) website (vohc.com) to form proper client recommendations rather than relying on marketing statements.
Diets for Dental Care
Traditional dry dog foods have been thought to be helpful in controlling gum disease, and one study supports these claims.67 However, another study found that dry food does not perform better than moist food in regards to oral health.68 Therefore, a specific dental diet that has been proven to decrease tartar and plaque accumulation should be selected.69
Several diets have received the VOHC seal as effective against both plaque and calculus reduction. A smaller number of diets have received VOHC approval for calculus reduction only. Although these products may decrease plaque and calculus, they are typically only effective on the cusp tips and do not clean along the gingival margin.70 Of all the available diets, only one has been proven to decrease gingivitis.71-73
Plaque and/or Calculus Control Treats
Several edible treats are available for passive homecare; however, their effectiveness varies, and practitioners are again encouraged to consult the VOHC website in their search for effective products. The most common are the rask-type chews (products composed of compressed wheat, cellulose, or rawhide).74-79 A few products have been shown to decrease gingivitis.77,80-86 In addition, a few products have received VOHC approval for plaque and/or calculus control. A product containing the brown algae Ascophyllum nodosum has been shown to improve oral health status.87 Plain baked biscuit treats and chew toys (e.g., rope toys) are not effective in the prevention of periodontitis.74
Many “dental treats” or chew toys are very hard, which can result in tooth fracture.88 As a rule of thumb, clients can be advised that if they cannot make an indentation in the product with their fingernail, it is too hard.50
Lifelong periodontal care benefits the patient, the client, and the practice. Performing regular (and early) professional dental cleanings, training staff in the proper performance of periodontal care, and establishing the value of homecare early in a pet’s life through client education allow the maximal benefit of this lifelong effort to be achieved. Also, as proper cleaning can only be performed within the clinic, periodontal therapy makes the dental department a critical area of medical care, as well as a significant financial center. Avoiding periodontal disease must be the goal, for once it is established, damage is typically irreversible and more invasive care, including surgery and, eventually, tooth extraction, will be necessary.
1. Niemiec BA. Etiology and pathogenesis of periodontal disease. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2012:18-32.
2. Niemiec BA. Advanced non-surgical therapy. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley-Blackwell;
3. Bellows J, Berg ML, Dennis S, et al. 2019 AAHA dental care guidelines for dogs and cats. JAAHA 2019;55(2):49-69.
4. Colmery B. The gold standard of veterinary oral health care. Vet Clin North Am Small Anim Pract 2005;35(4):781-787.
5. Niemiec BA. Professional teeth cleaning. J Vet Dent 2003;20(3):175-180.
6. Bellows J. Equipping the dental practice. In: Bellows J, ed. Small Animal Dental Equipment, Materials, and Techniques: A Primer. Ames, IA: Blackwell; 2004:13-55.
7. Holmstrom SE, Fitch PF, Eisner ER. Dental prophylaxis and periodontal disease stages. Veterinary Dental Techniques. 3rd ed. Philadelphia, PA: Saunders; 2002:175-232.
8. Holmstrom SE, Bellows J, Juriga S, et al. 2013 AAHA dental care guidelines for dogs and cats. JAAHA 2013;49(2):75-82.
9. Huffman LJ. Oral examination. In: Niemiec BA, ed. Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. London: Manson; 2010:39-61.
10. Stella JL, Bauer AE, Croney CC. A cross-sectional study to estimate prevalence of periodontal disease in a population of dogs (Canis familiaris) in commercial breeding facilities in Indiana and Illinois.
PLoS One 2018;13(1):e0191395.
11. Urfer SR, Wang M, Yang M, et al. Risk factors associated with lifespan in pet dogs evaluated in primary care veterinary hospitals. JAAHA 2019;55(3):130-137.
12. Bauer AE, Stella J, Lemmons M, Croney CC. Evaluating the validity and reliability of a visual dental scale for detection of periodontal disease (PD) in non-anesthetized dogs (Canis familiaris). PLoS One 2018;13(9):e0203930.
13. Wallis C, Patel KV, Marshall M, et al. A longitudinal assessment of periodontal health status in 53 Labrador retrievers. J Small Anim Pract 2018;59(9):560-569.
14. Companion animal dental scaling without anesthesia. American College of Veterinary Dentists. avdc.org/about/#pos-stmts. Accessed May 2018.
15. Global dental guidelines. World Small Animal Veterinary Association. wsava.org/Global-Guidelines/Global-Dental-Guidelines. Accessed May 2018.
16. Niemiec BA. The complete dental cleaning. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley Blackwell; 2013:129-153.
17. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in cats. Am J Vet Res 1998;59(6):692-695.
18. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res 1998;59(6):686-691.
19. Engler W, Bain M. Effect of different types of classical music played at a veterinary hospital on dog behavior and owner satisfaction. JAVMA 2017;251(2):195-200.
20. Gilbert C, Mikaelsson A, Gilbert S. Enhancing dogs’ welfare during a veterinary consultation; impact of environmental factors and positive interactions before the consultation. Proc Eur Cong Behav Med Anim Welf 2018:254-255.
21. Hekman JP, Karas AZ, Sharp CR. Psychogenic stress in hospitalized dogs: cross species comparisons, implications for health care, and the challenges of evaluation. Animals 2014;4(2):331-347.
22. Savvas I, Raptopoulos D, Rallis T. A “light meal” three hours pre-operatively decreases the incidence of gastro-esophageal reflux in dogs. JAAHA 2016;52(6):357-363.
23. Savvas I, Rallis T, Raptopoulos D. The effect of pre-anesthetic fasting time and type of food on gastric content volume and acidity in dogs. Vet Anaesth Analg 2009;36(6):539-546.
24. Westlund K. To feed or not to feed: counterconditioning in the veterinary clinic. J Vet Behav 2015;10:433-437.
25. Beckman B. Patient management for periodontal therapy. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2012:305-312.
26. Hughes J. Anaesthesia for the geriatric dog and cat. Ir Vet J 2008;61(6):380–387.
27. Lloyd JKF. Minimising stress for patients in the veterinary hospital: why it is important and what can be done about it. Vet Sci 2017;4(2):22.
28. Tynes VV. The physiologic effects of fear. Vet Med. veterinarymedicine.dvm360.com/physiologic-effects-fear. Accessed December 2016.
29. Watanabe R, Doodnaught G, Proulx C, et al. A multidisciplinary study of pain in cats undergoing dental extractions: a prospective, blinded, clinical trial. PLoS One 2019;14(3):e0213195.
30. Zetner K , Rothmueller G. Treatment of periodontal pockets with doxycycline in beagles. Vet Ther 2002;3(4):441–452.
31. Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol 1986;13(3):205-210.
32. Carranza FA, Takei HH. Phase II periodontal therapy. In: Newman MG, Takei H, Klokkevold PR, et al, eds. Carranza’s Clinical Periodontology. St. Louis, MO: WB Saunders; 2006:881-886.
33. Danser MM, van Winkelhoff AJ, de Graaff J, et al. Short-term effect of full-mouth extraction on periodontal pathogens colonizing the oral mucous membranes. J Clin Periodontol 1994;21:484.
34. Niemiec BA. Periodontal flap surgery. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: John Wiley and Sons; 2012:206-248.
35. Martel DP, Fox PR, Lamb KE, et al. Comparison of closed root planing with versus without concurrent doxycycline hyclate or clindamycin hydrochloride gel application for the treatment of periodontal disease in dogs. JAMVA 2019;254(3):373-379.
36. Gulati M, Anand V, Govila V, et al. Host modulation therapy: an indispensable part of perioceutics. J Indian Soc Periodontol 2014;18(3):282-288.
37. Mahajania M, Laddha R, Shelke A, et al. Effect of subgingival doxycycline placement on clinical and microbiological parameters in inflammatory periodontal disease: both in vivo and in vitro studies.
J Contemp Dent Pract 2018;19(10):1228-1234.
38. Jeffcoat MK, Bray KS, Ciancio SG, et al. Adjunctive use of a subgingival controlled-release chlorhexidine chip reduces probing depth and improves attachment level compared with scaling and root planing alone. J Periodontol 1998;69(9):989–997.
39. Niemiec BA. Osseous surgery and guided tissue regeneration. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2012:254-288.
40. Wiggs RB, Lobprise HB. Periodontology. In: Wiggs RB, Lobprise HB, eds. Veterinary Dentistry: Principles and Practice. Philadelphia, PA: Lippincott–Raven; 1997:186-231.
41. Boyce EN, Ching RJ, Logan EI, et al. Occurrence of gram-negative black-pigmented anaerobes in subgingival plaque during the development of canine periodontal disease. Clin Infect Dis 1995;20(Suppl 2):S317-S319.
42. Watanabe K, Kijima S, Nonaka C, et al. Inhibitory effect for proliferation of oral bacteria in dogs by tooth brushing and application of toothpaste. J Vet Med Sci 2016;78(7):1205-1208.
43. Debowes LJ. Problems with the gingiva. In: Niemiec BA, ed. Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. London: Manson; 2010:159-181.
44. Fiorellini JP, Ishikawa SO, Kim DM. Clinical features of gingivitis. In: Newman MG, Takei H, Klokkevold PR, et al, eds. Carranza’s Clinical Periodontology. St. Louis, MO: WB Saunders; 2006:362-372.
45. Rober M. Effect of scaling and root planing without dental homecare on the subgingival microbiota. Proc Eur Cong Vet Dent 2007:28-30.
46. Corba NHC, Jansen J, Pilot T. Artificial periodontal defects and frequency of tooth brushing in beagle dogs (II). Clinical findings after a period of healing. J Clin Periodontol 1986;13(3):186-189.
47. Payne WA, Page RC, Olgilvie AL, Hall WB. Histopathologic features of the initial and early stages of experimental gingivitis in man. J Periodont Res 1975;10(2):51.
48. Capik I. Periodontal health vs. different preventive means in toy breeds—clinical study. Proc Eur Cong Vet Dent 2007:31-34.
49. Niemiec BA. Home plaque control. In: Niemiec BA, ed. Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2012:175-185.
50. Hale FA. Home care for the veterinary dental patient. J Vet Dent 2003;20(1):52-54.
51. Watanabe K, Hayashi K, Kijima S, et al. Tooth brushing inhibits oral bacteria in dogs. J Vet Med Sci 2015;77(10):1323-1325.
52. Stratul SI, Rusu D, Didilescu A, et al. Prospective clinical study evaluating the long-time adjunctive use of chlorhexidine after one-stage full-mouth SRP. Int J Dent Hyg 2010;8(1):35-40.
53. Eaton KA, Rimini FM, Zak E, et al. The effects of a 0.12% chlorhexidine-digluconate containing mouthrinse versus a placebo on plaque and gingival inflammation over a 3-month period. A multicentre study carried out in general dental practices. J Clin Periodontol 1997;24(3):189-197.
54. Hennet P. Effectiveness of a dental gel to reduce plaque in beagle dogs. J Vet Dent 2002;19(1):11-14.
55. Hamp SE, Emilson CG. Some effects of chlorhexidine on the plaque flora of the beagle dog. J Periodontol Res Suppl 1973;12:28-35.
56. Hull PS, Davies RM. The effect of a chlorhexidine gel on tooth deposits in beagle dogs. J Small Anim Pract 1972;13:207-212.
57. Maruniak J, Clark WB, Walker CB, et al. The effect of 3 mouthrinses on plaque and gingivitis development. J Clin Periodontol 1992;19(1):19-23.
58. Wolinsky LE, Cuomo J, Quesada K, et al. A comparative pilot study of the effects of a dentifrice containing green tea bioflavonids, sanguinarine, or triclosan on oral bacterial biofilm formation. J Clin Dent 2000;11(2):53-59.
59. Clarke DE. Clinical and microbiological effects of oral zinc ascorbate gel in cats. J Vet Dent 2001;18(4):177-183.
60. Niemiec BA. Periodontal disease. Top Companion Anim Med 2008;23(2):72-80.
61. Harvey C, Serfilippi L, Barnvos D. Effect of frequency of brushing teeth on plaque and calculus accumulation, and gingivitis in dogs. J Vet Dent 2015;32(1):16-21.
62. Gorrel C, Rawlings JM. The role of tooth-brushing and diet in the maintenance of periodontal health in dogs. J Vet Dent
63. Tromp JA, Jansen J, Pilot T. Gingival health and frequency of tooth brushing in the beagle dog model. Clinical findings. J Clin Periodontol 1986;13(2):164-168.
64. Ingham KE, Gorrel C. Effect of long-term intermittent periodontal care on canine periodontal disease. J Small Anim Pract 2001;42(2):67-70.
65. Miller BR, Harvey CE. Compliance with oral hygiene recommendations following periodontal treatment in client-owned dogs. J Vet Dent 1994;11(1):18-19.
66. Vrieling HE, Theyse LF, van Winkelhoff AJ, et al. Effectiveness of feeding large kibbles with mechanical cleaning properties in cats with gingivitis. Tijdschr Diergeneeskd 2005;130(5):136-140.
67. Gawor JP, Reiter AM, Jodkowska K, et al. Influence of diet on oral health in cats and dogs. J Nutr 2006;136(7 suppl):2021S-2023S.
68. Harvey CE, Shofer FS, Laster L. Correlation of diet, other chewing activities, and periodontal disease in North American client-owned dogs. J Vet Dent 1996;13(3):101-105.
69. Jensen L, Logan E, Finney O, et al. Reduction in accumulation of plaque, stain, and calculus in dogs by dietary means. J Vet Dent 1995;12(4):161-163.
70. Stookey GK, Warrick JM. Calculus prevention in dogs provided diets coated with HMP. Proc Am Vet Dent Forum 2005:417-421.
71. Logan EI, Finney O, Hefferren JJ. Effects of a dental food on plaque accumulation and gingival health in dogs. J Vet Dent 2002;19(1):15-18.
72. Logan EI, Proctor V, Berg ML, et al. Dietary effect on tooth surface debris and gingival health in cats. Proc Am Vet Dent Forum 2001:77.
73. Logan EI, Berg ML, Coffman L, et al. Dietary control of feline gingivitis: results of a six month study. Proc Vet Dent Forum 1999:54.
74. Roudebush P, Logan E, Hale FA. Evidence-based veterinary dentistry: a systematic review of homecare for prevention of periodontal disease in dogs and cats. J Vet Dent 2005;22(1):6-15.
75. Hennet P, Servet E, Venet C. Effectiveness of an oral hygiene chew to reduce dental deposits in small breed dogs. J Vet Dent 2006;23(1):6-12.
76. Lage A, Lausen N, Tracy R, Allred E. Effect of chewing rawhide and cereal biscuit on removal of dental calculus in dogs. JAVMA
77. Stookey GK. Soft rawhide reduces calculus formation in dogs. J Vet Dent 2009;26:82-85.
78. Hennet P. Effectiveness of an enzymatic rawhide dental chew to reduce plaque in beagle dogs. J Vet Dent 2001;18(2):61-64.
79. Beynen AC, Van Altena F, Visser EA. Beneficial effect of a cellulose-containing chew treat on canine periodontal disease in a double-blind, placebo-controlled trial. Am J Anim Vet Sci 2010;5:192-195.
80. Gorrel C, Bierer TL. Long-term effects of a dental hygiene chew on the periodontal health of dogs. J Vet Dent 1999;16(3):109-113.
81. Gorrel C, Warrick J, Bierer TL. Effect of a new dental hygiene chew on periodontal health in dogs. J Vet Dent 1999;16(2):77-81.
82. Mariani C, Douhain J, Servet E, et al. Effect of toothbrushing and chew distribution on halitosis in dogs. Proc Cong Vet Dent 2009:13-15.
83. Warrick JM, Stookey GK, Inskeep GA, et al. Reducing calculus accumulation in dogs using an innovative rawhide treat system coated with hexametaphosphate. Proc Am Vet Dent Forum 2001:379-382.
84. Brown WY, McGenity P. Effective periodontal disease control using dental hygiene chews. J Vet Dent 2005;22(1):16-19.
85. Quest BW. Oral health benefits of a daily dental chew in dogs. J Vet Dent 2013;30(2):84-87.
86. Clarke DE, Kelman M, Perkins N. Effectiveness of a vegetable dental chew on periodontal disease parameters in toy breed dogs. J Vet Dent 2011;28(4):230-235.
87. Gawor J, Jank M, Jodkowska K, et al. Effects of edible treats containing Ascophyllum nodosum on the oral health of dogs: a double-blind, randomized, placebo-controlled single-center study. Front Vet Sci 2018;5:168.
88. Soltero-Rivera M, Elliott MI, Hast MW, et al. Fracture limits of maxillary fourth premolar teeth in domestic dogs under applied forces. Front Vet Sci 2019;5:339.