Featured , Nutrition , Nutrition Notes

Effects of Diets, Treats, and Additives on Periodontal Disease

Alexander M. Reiter Dipl. Tzt., Dr. med. vet., DAVDC, DEVDC

Dr. Reiter graduated from the University of Veterinary Medicine in Vienna, Austria, in 1996. He completed a dentistry and oral surgery residency at the University of Pennsylvania School of Veterinary Medicine in 2000 and became a Diplomate of the American Veterinary Dental College (AVDC) and European Veterinary Dental College (EVDC) in 2001. Dr. Reiter is Professor of Dentistry and Oral Surgery at the University of Pennsylvania School of Veterinary Medicine’s small animal hospital as well as Head of the Dentistry and Oral Surgery Service and Director of the Dentistry and Oral Surgery Residency Program. He is also a Founding Fellow, AVDC Oral and Maxillofacial Surgery. His clinical and research interests include dental, periodontal, oral, and maxillofacial disease epidemiology; advanced periodontal surgery; bone grafting procedures; oral and maxillofacial surgery (trauma and oncology); palate surgery and palatal prosthetics; maxillofacial reconstruction; microsurgery (free microvascular tissue transfer); oral manifestation of systemic disease; and systemic manifestation of oral disease.

Effects of Diets, Treats, and Additives on Periodontal Disease
TREATS AND TEETH The gold standard for preventing periodontal disease is professionally cleaned teeth, but there are some foods, treats, and additives that can help reduce plaque and calculus buildup. Christian Buch/Shutterstock.com
  •  
  •  
  •  
  •  
  •  
  •  
  •  

Teeth help increase the surface area of food by making individual pieces of food smaller, thus allowing for better mixing of food with the lubricating saliva before the bolus of food is swallowed. The teeth are held in position by the periodontium, which is made up of the gingiva, periodontal ligament, alveolar bone, and cementum. When the periodontium becomes infected or inflamed because of plaque bacteria and the host’s response to the bacterial insult, periodontal disease (gingivitis and periodontitis) is the result.1

PERIODONTAL DISEASE

Gingivitis (inflammation of the gingiva) is the less severe form of periodontal disease and can be treated with proper oral hygiene.

Periodontitis affects the gingival and nongingival components of the periodontium, resulting in tooth attachment loss, gingival recession, root exposure, furcation exposure, pocket formation, and bone loss. Clinical signs vary widely (BOX 1). Treatment depends on the severity of periodontal disease and may range from professional dental cleaning, closed periodontal therapy (root planing, gingival curettage), administration of antiseptic and anti-inflammatory medications, open periodontal therapy (improved access to diseased tissues after creation of a flap), and complex flap and bone grafting procedures to extraction of nonsalvageable teeth.

BOX 1 Signs of Oral and Dental Diseases in Dog and Cats
  • Decreased appetite, weight loss
  • Bad breath (malodor, halitosis)
  • Dental deposits (plaque, calculus [tartar]), particularly when asymmetrical
  • Preferential chewing on one side
  • Mobile, malpositioned, and/or fractured teeth
  • Inability or reluctance to open or close the mouth
  • Dropping food from the mouth
  • Oral inflammation (individual ulcers, widespread stomatitis)
  • Oral discharge (e.g., drooling saliva, bleeding, pus)
  • Sneezing, nasal discharge, decreased airflow from one nostril
  • Ocular discharge, exophthalmos/enophthalmos
  • Facial/head asymmetry, oral and/or maxillofacial swellings
  • Extraoral and/or intraoral sinus tracts
  • Regional lymphadenomegaly
  • Vocalizing, pawing at the face, repetitive lower jaw motions
  • Uncooperative behavior during examination, pain on touch

In an otherwise healthy patient, periodontal disease can lead to bacteremia, but it is rapidly cleared by the reticuloendothelial system.2 Thus, routine use of systemic antibiotics is discouraged and required only for selected patients with conditions that could worsen during or after a dental or oral surgery procedure (e.g., established organ disease, immunosuppression). In addition to bacteremia, periodontal disease can lead to the chronic release of inflammatory mediators, immune complexes, and byproducts of bacterial and cellular degradation into the blood and lymph vessels, which could produce direct or immune-mediated organ pathology (e.g., liver, kidney, and myocardium in dogs).1

PREVENTING OR MANAGING PERIODONTAL DISEASE

To be able to make appropriate recommendations, the veterinary professional should always ask clients about any home oral hygiene that they may perform for their pet; their pet’s chewing habits and diet; and which, if any, chewing objects they offer their pet.3 As mentioned, there are many professional treatment options for periodontal disease; this article focuses on products available to help clients prevent or manage periodontal disease at home.

Home Oral Hygiene

No discussion of oral health would be complete without mentioning home oral hygiene, a critical component of oral health maintenance. Plaque is soft enough to be brushed or wiped off; however, if allowed to accumulate for 2 to 3 days, plaque becomes mineralized to form calculus (tartar), which resists removal by tooth brushing or mastication (although some dental diets and chews may remove some calculus via the process of chewing). Thus, to remove plaque before it mineralizes, toothbrushing needs to be done daily or at least every other day.4 Pet-specific toothbrushes are available; some are angled to assist in brushing the caudal teeth. Cats and small dogs often prefer finger brushes. Regardless of what type of brush is used, the bristles of the brush must be soft. Other products that can be used to remove plaque from the tooth surfaces include medicated wipes, gauze, and cotton-tipped applicators. Pet dentifrices (pastes or powders) are also available and come in many flavors; some are more abrasive for working on calculus and others contain enzymes to reduce plaque.5

Products for Improving Oral Health

Products that reduce plaque and calculus buildup include dental diets; chews, treats, and toys; and drinking water or food additives.6 Oral rinses, gels, and toothpastes are also effective but fall outside the scope of this article. The Veterinary Oral Health Council (VOHC; vohc.org) is an entity of the American Veterinary Dental College and awards a seal of acceptance to products that meet pre-set criteria for mechanically and/or chemically controlling plaque and/or calculus deposition in dogs and cats. Clients often educate themselves through the Internet, and they can be confident that the marketing claims are credible for products that have been awarded the VOHC Seal of Acceptance. However, VOHC is not a regulatory agency, and submission of clinical trial results to the VOHC on behalf of a company is voluntary. Furthermore, VOHC does not determine the safety of a product but requires assurance by the company that a product is safe and meets all applicable regulatory requirements.5

Dental Diets

A study in Australia compared the oral health of domestic cats eating commercially available canned and dry diets with that of feral cats whose diets consisted of small mammals, birds, reptiles and insects. Researchers found that calculus accumulation was more severe in the domestic cats but prevalence of periodontal disease did not differ significantly between the 2 groups.7 For reasons of food safety, pets should generally not be fed raw meat or unpasteurized dairy products.5

In terms of food texture, another study found that compared with soft and mixed (dry and soft) food, dry food had a positive influence on the oral health of cats and dogs, decreasing the occurrence of mandibular lymphadenopathy, accumulation of dental deposits, and development of periodontal disease.8 Oral health also improved significantly in cats and dogs fed a commercial dry diet compared with those fed a home-prepared diet.9 Cats fed large kibbles had significantly less gingivitis and calculus than did cats fed small kibbles.10 Specially engineered dry kibble with added polyphosphates or chlorhexidine provides the mechanical and chemical actions, respectively, to prevent or retard plaque and calculus formation. Long fibers within a large kibble oriented in one direction help to keep the kibble from crumbling when a dog or cat bites into it. This design allows the kibble to mechanically scrape the sides of the teeth as they penetrate it.11,12

Studies in cats demonstrated that the daily addition of a dental treat to the dry diet resulted in significantly less plaque and calculus accumulation on tooth surfaces.19,20

Chews, Treats, and Toys

Dental chews and treats given daily have been shown to reduce plaque and calculus accumulation, gingivitis, and bad breath in dogs.13-15 Rawhides in particular seemed to have a protective effect against periodontal disease; this effect was more obvious in dogs fed dry food only.16 Note, however, that there have been some reports of potential rawhide contamination with Salmonella. The inclusion of polyphosphates or chlorhexidine may further improve the effectiveness of a chew or treat.17 However, the decisive factor in maintaining oral health in dogs seems to be the abrasiveness of the product rather than the activity of the added chemical.18 Studies in cats demonstrated that the daily addition of a dental treat to the dry diet resulted in significantly less plaque and calculus accumulation on tooth surfaces.19,20 The size and shape of any chew, treat, or toy should be matched with the chewing habits of the pet. Chewing objects should not be too hard because very hard materials can fracture teeth.21 Inappropriate items include plastic bones made of hard nylon, cow hooves, antlers, rocks, large ice cubes, and wooden sticks. Meat bones (cooked and uncooked) are also too hard and carry the risk of esophageal obstruction and gastrointestinal perforation. Tennis balls are very abrasive to teeth because they collect tiny particles of dirt and sand and will wear down the crowns, leading to pulp exposure.5

Food and Water Additives

Some plaque or calculus-retarding agents can also be added as a liquid to the drinking water or as a powder to the food.22 Pet owners generally should avoid products with unsubstantiated or unreasonable claims (e.g., “no more brushing of teeth needed,” “replaces general anesthesia for dental cleanings”).

Despite the value of the above-mentioned products (diets, chews/treats, water/food additives), none replaces thorough oral examinations (including periodontal probing and dental radiography) and dental cleanings (including root planing and gingival curettage) performed by trained veterinary professionals. The gold standard for the management of periodontal disease is diagnosis and treatment under general anesthesia, followed by home oral hygiene (daily toothbrushing and proper nutrition). Anesthesia-free dental cleaning done by untrained persons may be cosmetically pleasing to some pet owners, but it provides a false sense of accomplishment by making parts of the crowns look good while neglecting the subgingival areas of the teeth where periodontal disease is active.5 A painful mouth will make for a noncompliant pet and may cause the client to give up completely on toothbrushing and other home oral hygiene measures. Thus, it is often best to start with professionally cleaned teeth and healthy gums, which will be hugely motivating to the client and far more beneficial to the pet (FIGURE 1).5

References

1. Reiter AM. Commonly encountered dental and oral pathologies. In: Reiter AM, Gracis M, eds. BSAVA Manual of Canine and Feline Dentistry and Oral Surgery. 4th ed. Gloucester, UK: BSAVA; 2018:89-118.

2. Silver JG, Martin L, McBride BC. Recovery and clearance of oral micro-organisms following experimental bacteremia in dogs. Arch Oral Biol 1975;20(10):675-679.

3. Kirby S, Miller B. Dental and oral examination and recording. In: Reiter AM, Gracis M, eds. BSAVA Manual of Canine and Feline Dentistry and Oral Surgery. 4th ed. Gloucester, UK: BSAVA; 2018:33-48.

4. 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.

5. Reiter AM, Castejon-Gonzalez A. Perioperative considerations in dentistry and oral surgery. In: Reiter AM, Gracis M, eds. BSAVA Manual of Canine and Feline Dentistry and Oral Surgery. 4th ed. Gloucester, UK: BSAVA; 2018:338-370.

6. 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.

7. Clarke DE, Cameron A. Relationship between diet, dental calculus and periodontal disease in domestic and feral cats in Australia. Aust Vet J 1998;76(10):690-693.

8. 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.

9. Buckley C, Colyer A, Skrzywanek M, et al. The impact of home-prepared diets and home oral hygiene on oral health in cats and dogs. Br J Nutr 2011;106(Suppl 1):S124-S127.

10. Vrieling HE, Theyse LRF, Winkelhoff van AJ, et al. Effectiveness of feeding large kibbles with mechanical cleaning properties in cats with gingivitis [in Dutch]. TijdschrDiergeneeskd 2005;130(5):136-140.

11. 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.

12. Logan EI. Dietary influences on periodontal health in dogs and cats. Vet Clin North Am Small Anim Pract 2006;36(6):1385-1401.

13. Clarke DE, Servet E, Hendriks W, et al. Effect of kibble size, shape, and additives on plaque in cats. J Vet Dent 2010;27(2):84-89.

14. 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.

15. Quest BW. Oral health benefits of a daily dental chew in dogs. J Vet Dent 2013;30(2):84-87.

16. 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.

17. Rawlings JM, Gorrel C, Markwell PJ. Effect on canine oral health of adding chlorhexidine to a dental hygiene chew. J Vet Dent 1998;15(3):129-134.

18. Brown WY, McGenity P. Effective periodontal disease control using dental hygiene chews. J Vet Dent 2005;22(1):16-19.

19. Gorrel C, Inskeep G, Inskeep T. Benefits of a ‘dental hygiene chew’ on the periodontal health of cats. J Vet Dent 1998;15(3):135-138.

20. Ingham KE, Gorrel C, Bierer TL. Effect of a dental chew on dental substrates and gingivitis in cats. J Vet Dent 2002;19(4):201-204.

21. 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.

22. Clarke DE. Drinking water additive decreases plaque and calculus accumulation in cats. J Vet Dent 2006;23(2):79-82.

DMCA.com Protection Status
[gravityform id="6" title="false" description="false"]
<div class='gf_browser_chrome gform_wrapper' id='gform_wrapper_6' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_6' action='/effects-of-diets-treats-and-additives-on-periodontal-disease/'> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_1' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_3' >First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_6' >Last</label> </span> </div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_7' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_7' >Profession / Role<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Veterinarian' >Veterinarian</option><option value='Veterinary Nurse / Technician' >Veterinary Nurse / Technician</option><option value='Practice Manager / Veterinary Assistant / Support Staff' >Practice Manager / Veterinary Assistant / Support Staff</option><option value='Student (Veterinarian or Veterinary Nurse)' >Student (Veterinarian or Veterinary Nurse)</option><option value='Other' >Other</option></select></div></li><li id='field_6_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_15' class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' >Inbox Preferences</label><div class='gfield_description' id='gfield_description_6_15'>Customize your inbox by selecting the areas you are most interested in. </div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='NAVC Better Care Weekly&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.&lt;/div&gt;' checked='checked' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>NAVC Better Care Weekly<br><div style="font-size: 12px; color: #808080;">A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.</div></label> </li><li class='gchoice_6_15_2'> <input name='input_15.2' type='checkbox' value='Today&#039;s Veterinary Business eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.&lt;/div&gt;' id='choice_6_15_2' /> <label for='choice_6_15_2' id='label_6_15_2'>Today's Veterinary Business eNewsletter<br><div style="font-size: 12px; color: #808080;">Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.</div></label> </li><li class='gchoice_6_15_3'> <input name='input_15.3' type='checkbox' value='Today&#039;s Veterinary Nurse eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.&lt;/div&gt;' id='choice_6_15_3' /> <label for='choice_6_15_3' id='label_6_15_3'>Today's Veterinary Nurse eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.</div></label> </li><li class='gchoice_6_15_4'> <input name='input_15.4' type='checkbox' value='Today&#039;s Veterinary Practice eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div><script type='text/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 6) {gf_global["number_formats"][6] = {"1":{"price":false,"value":false},"2":{"price":false,"value":false},"7":{"price":false,"value":false},"20":{"price":false,"value":false},"15":{"price":false,"value":false},"19":{"price":false,"value":false},"22":{"price":false,"value":false},"10":{"price":false,"value":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][6] = { logic: { 10: {"field":{"actionType":"show","logicType":"any","rules":[{"fieldId":"22","operator":"is","value":"Yes, I love mail!"}]},"nextButton":null,"section":null} }, dependents: { 10: [10] }, animation: 1, defaults: {"1":{"1.2":"","1.3":"","1.4":"","1.6":"","1.8":""},"15":["choice_6_15_1"],"10":{"10.1":"","10.2":"","10.3":"","10.4":"","10.5":"","10.6":""}}, fields: {"1":[],"2":[],"7":[],"20":[],"15":[],"19":[],"22":[10],"10":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(6, [10], true);jQuery('#gform_wrapper_6').show();jQuery(document).trigger('gform_post_conditional_logic', [6, null, true]);} );} gformInitChosenFields('#input_6_7','No results matched');} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){gformInitChosenFields('#input_6_7','No results matched');} );</script><script type='text/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [6, 1]) } ); </script>
MENU