Jim Berry: [00:00:00] Welcome to the WSAVA Podcast. Today's discussion explores oral and systemic health, an area that reminds us that disease in the mouth rarely exists in isolation. As you listen, consider this, how often do oral conditions influence the wider health and welfare of your patients? Our interviewer, David Clarke, speaks first with Maria Soltero-Rivera, and later with Jen Mathis. Let's listen in. David Clarke: Welcome, Maria. Maria Soltero-Rivera: Thank you for having me, David. This is a very exciting topic, so I'm glad I could be part of this. David Clarke: Yeah, we're super excited to have you as well. I thought we'd start with a basic outline of what we currently know about the key systemic consequences of chronic oral diseases in dogs and cats? Maria Soltero-Rivera: I think that's a great place to start. What we now understand is that chronic oral disease in dogs and cats is rarely just a local problem. There's a wide range of systemic disorders, immune-mediated, infectious, [00:01:00] metabolic, nutritional, endocrine, neoplastic diseases that really have manifestations in the oral cavity. Those can be direct or indirect. Oral lesions may be the first or only visible sign of something that has a broader systemic implication in our patients and it's important to know that sometimes we're treating oral disease, but we don't think about having to treat the underlying disease to really get to the point where we wanna get in improving the animal's quality of life and resolving those oral lesions. I think that oral inflammation reflects how it can play a role in systemic dysregulation. It can go both ways. You can have systemic disease manifesting as oral disease and oral disease affecting the systemic immune system and so it's important to consider the mouth as the window of the rest of the body. That's the way I explain it to students here. I think it's a biologically active participant in systemic disease. David Clarke: Yeah. Yeah. That's interesting, isn't it? Because like you just said, the oral [00:02:00] disease could affect the systemic disease and vice versa, so they're related. Do you think there's any particular patient groups that it affects? Maria Soltero-Rivera: Yeah. That's a good question. I think there are some populations that probably deserve special attention. This brings us to the concept of personalised medicine, right? We don't wanna treat every patient the same way because every patient has different needs. I think that geriatric patients, those with endocrine diseases, paediatric patients, those we know their immune system can be a little bit different and working in different ways. Patients receiving certain medications that can affect the oral cavity, bone and teeth are probably patients that you want to pay close attention to. Those are animals that are probably gonna develop oral manifestations related to these treatments or systemic dysfunctions and then you have to think about those oral lesions having a multifactorial cause because yes, of course we see periodontal disease very commonly in our dogs and cats. They do fracture their teeth. They can have primary dental disease, but these animals have primary dental disease [00:03:00] plus, right? David Clarke: Yeah. Maria Soltero-Rivera: When those patients, the oral disease can signal worsening of systemic disease, you can see an adverse drug reaction that manifests as oral disease, or you can see the start of metabolic or infectious disease. It is important to monitor the oral cavity in the context of medical monitoring for our patients and not just consider it as an isolated procedure. David Clarke: One thing I've noticed with my travels around the world and talking to a lot of general practitioners is that a lot of them seem to underestimate the medical impact of inflammation in their mouth. Why do you think that this sort of gap is underestimated by general practitioners? Maria Soltero-Rivera: That's a great question. I think that's the old adage of maybe it's seen me, but I haven't seen it. I think we don't know a lot about this. There's probably, that's the major reason why the link remains underestimated and it's that we have very limited research and systematic research focused on the oral manifestations of systemic disease. We extrapolate the knowledge [00:04:00] from human medicine, and our oral findings are often under recognised in animals because they're not very good about telling us when they have oral pain or lesions. Some of them don't tolerate oral examinations awake, and so it's hard to recognize the disease when it exists. Dentistry has been historically seen as procedure based rather than medical based and so there's this need of shifting that mindset of dentistry, not only surgery, that emphasises that oral lesions can be diagnostic clues of systemic disease. Comprehensive evaluations should be done not only by us, but also by internal medicine specialists and oncologists, as again, having a more complete picture of what's happening with the patient in general. David Clarke: One thing I've found in my travels is a lot of veterinarians treat dentistry as an elective service rather than core medicine. Did you have any other ideas on how we could focus [00:05:00] practitioners on getting dentistry to be part of their core business and the whole health aspect of the animal? Maria Soltero-Rivera: I think I always bring it back to having people relate what their animal needs are to what your needs are and so I explain to owners, you go to the dentist at least once to twice a year. They have teeth too. They need to use it just as much as you do, so why not look at the oral cavity? I bring it back to their experience to create some analogies that might be helpful for them to understand the importance. I tell them a little bit about the history of dentistry when it started, and that kind of explains why a lot of people will say, historically, I've had many dogs and I have never had to worry about teeth. Historically, we didn't know that we had to worry about teeth, our profession's fairly young, and there's a lot of education that still is necessary at the owner level, but also at the primary care practitioner level. With time, we've gotten better and better at it, but I think also the other [00:06:00] layer to think about is that the oral cavities a continuum with the rest of the body, it's not disconnected. It connects to the respiratory system, to the gastrointestinal tracts, or the gastrointestinal tract technically speaking, and it's the first encounter between the outside environment and your body. So it's constantly being bombarded by insults that have to be managed. It's exposed to the world and so when I explain things that way, people kind of start thinking about it more in the context of a need rather than a luxury. David Clarke: Never really thought about it like that. That's a really brilliant way to describe it as the window to your soul, so to speak. Maria Soltero-Rivera: I think we've been under utilising the oral cavity incredibly. If you think about it, the fact that in humans, oral lesions are the first sign of this gastrointestinal issue, and so. David Clarke: Yeah. Maria Soltero-Rivera: We've been severely under utilising the oral cavity. David Clarke: Yeah. Would there be signs or clinical presentations that veterinarians could look at to emphasise dental [00:07:00] treatment? And also maybe explain to their clients that it's not just the oral cavity? Maria Soltero-Rivera: Yeah, that's a good question. I think that when you're looking at the oral cavity things that might be considered red flags for me would be oral ulceration, anywhere in the oral cavity would raise a flag for me. Gingival enlargement, pale mucus membranes, petechia or chemosis, necrotic areas, any proliferative lesions in general, unexplained gingivitis that's very focal, asymmetric, or that is severe in the absence of other signs of peridontal disease, lesions that are multifocal or progressive. And those patterns make me think about could there be something immune mediated, infectious, metabolic, or neoplastic, rather than just these plaque related inflammatory conditions that we see and recognize as periodontal disease? I think periodontal disease has a pretty typical pattern of being symmetric unless it's acquired because you have a foreign body stuck between two [00:08:00] teeth. It tends to show along with, you see gingivitis, but you also see gingival recession, root exposure, mobility of teeth, tends to happen in the entire mouth, tends to happen in a certain breed of dogs, smaller dogs that are older. So when you start seeing things that are not fitting that pattern. So pattern recognition is key here. I think that location, what the lesion looks like and what your patient looks like are big cues. But also then does your patient, is it showing weight loss, lethargy, vomiting or diarrhoea? Any dermatologic diseases or things that don't quite fit with dental disease that's primary alone, should definitely be something that kind of raises a flag for, maybe this is a medical condition with secondary dental manifestations or oral manifestations and not just primary dental disease. David Clarke: I think it reminds me of the case I had quite a long time ago when I was younger and it came in with severe gingivitis referred by a general veterinarian. I thought clean its teeth and [00:09:00] everything will be fine. Then weeks go by and you've tried everything possible. It turned out to be lymphoma. Now looking back, I obviously link the oral disease to the systemic disease that has a pattern like you said. When you see those patterns, you think this is not actually a dental problem per se, it's more a medical related problem as well. I think you learn that with experience. Maria Soltero-Rivera: Yeah. To the students I put up during class two tables. One is the general description of a lesion. Is it a vesicle? Is it a papular? Is it a pustule? Is it a plaque? Is it? The same terminology that applies to dermatology, people don't realise, but can be applied to the oral cavity. Along with that, I put a table of the different locations in the oral cavity where you can have inflammation. I explained to them, you identify what the lesions look like, you identify the locations, and with enough time, you're gonna start recognising those patterns of for example, FCGS rarely causes inflammation of the hard palate, right? David Clarke: Yes. Maria Soltero-Rivera: But if you see a cat with oral inflammation, all [00:10:00] of a sudden you see the hard palate being involved. That's gonna be like red flag. This doesn't look like feline chronic gingival stomatitis. This might be something immune mediated or autoimmune. Again, you start thinking about those patterns, and I think we still have to do a lot more work in educating primary care practitioners in general or students about recognising those patterns that don't explain periodontal disease alone, or endodontal disease alone, or resorption. We've done a great job describing those. I think we still have to do a little bit more describing these other things that are manifestations of systemic disease or even oral mucosal disorders in general, to help with that recognition of diseases that are less commonly seen, but still relevant. David Clarke: That's true. I think your students are really fortunate having you there to explain to them these links between different diseases and show them patterns, et cetera. I think one of the problems with recent graduates is it's a challenge, as I found when I was an early practitioner or recent [00:11:00] graduate, is trying to communicate to clients the link between oral disease and systemic disease. You don't want to overwhelm the clients obviously. Do you have any ideas on how you could deliver that message efficiently without overwhelming them? Maria Soltero-Rivera: Yeah, good question. I think that is a key deficiency that we have to work through. But overall, I think with owners, keeping the message simple helps. As I mentioned before, I try to explain it as the mouth being the window to the body and being a continuum with the rest of the body. I try to explain, we specialise because we're in the business of trying to save teeth, but also we can recognize things that go above and beyond just the primary dental disease too. Explaining that oral inflammation can reflect immune, metabolic, or infectious diseases can help owners understand the importance of dental care in general, but your word alone sometimes doesn't do it. Sometimes having visual aids, pictures, analogies to [00:12:00] oral health can be very effective. So say a person that has suffered from any sort of oral disease, that might help them understand what's happening to their pet. I think the importance of explaining this to the owners also goes down to the fact that oral health shouldn't be considered elective medicine like you were explaining before, it's been considered as elective procedures in the past. Understanding that the oral cavity is that unique place that tells you more about the patient and the systemic health of the patient will ultimately help us provide better care, improve outcomes, and improve the patient's quality of life. I think however we can show this to the owners would be very helpful in general, and I think that as we move along in our research, that also will solidify the data that we can provide to the owners in manageable chunks, of course, but that strengthen this link between the oral cavity and systemic health. David Clarke: I think that's really important, linking the two [00:13:00] together and getting practitioners to understand that the mouth is really the window and it's the first contact that anything from outside your body, it doesn't go through your skin, actually enters your body, especially into your gastrointestinal system, obviously. Wow. A lot to think about. Maria Soltero-Rivera: Yeah, there's definitely a lot, a lot to think about, a lot to research, a lot to learn from and a lot to continue to educate people on. It's a very exciting growing field. I really enjoy this topic for that reason. I think we have so much work to do here. It's the type of stuff that inspires the work we do in our labs, and it's, I think, the time where we're seeing more and more progress on this compared to before. David Clarke: Thank you, Maria. Are there any final thoughts or words that you'd like to give to the listeners? Maria Soltero-Rivera: I think that being in a field where your patients can't talk to you, the more signals and cues that you can learn about them, the better. And I think [00:14:00] understanding that the oral cavity is yet another cue to discovering more information about their systemic health, it's just, just enlightening. It's another tool in your toolbox to provide the best care for your patients and hopefully diagnose them earlier and provide more well-rounded care to these animals that are such a positive influence to our lives and make such a big difference. So the better, the more fine tuned our care can be, the better their quality of life can be and their overall health. So the oral cavity is a good place to start, for sure. David Clarke: Wonderful, wonderful. Jim Berry: After Maria Soltero-Rivera, David Clarke is joined by Jen Mathis to discuss oral pain and animal welfare. David Clarke: Welcome, Jen. Jen Mathis: Thanks for inviting me, David. David Clarke: So Jen, let's start with something which is a fundamental question. Why is oral pain so frequently missed in veterinary patients? What are the subtle signs [00:15:00] or even some of the silent signs of discomfort that clinicians should be paying attention to? Jen Mathis: Well, your first question is, why is it so frequently missed? Most of the time there are no signs. The signs are hidden. There's some studies back from the nineties, both on dogs and cats that three out of every four patients have changes hidden on x-ray, and most of those have no symptoms. Sometimes a symptom may be bad breath, because what bad breath most of the time is the change of what's in your biofilm or plaque on the teeth. That doesn't mean it's caused bone loss yet, but it may easily have done so. Once things advance, you may see facial swelling. Occasionally you'll see sneezing with oral nasal fistulas. These are things that have been advanced. The common misconception is that owners and some veterinarians feel they'll stop eating if they have oral pain, but [00:16:00] I don't stop walking if I have a limp. But if they're not eating, it's usually oral cancer or stomatitis. Beyond that, almost all other symptoms of not eating relates to some internal med problem or something else beyond the mouth. So they probably have some other comorbidity. Most patients when they're painful, may be eating slowly and actually they've documented that in cats with tooth resorption. They eat slower, but they're still eating fine. Dogs may eat faster, snarfing food and not chewing it, but they still have pain because they don't wanna chew to have that pain. So there's some changes there as well. David Clarke: Obviously chronic pain doesn't affect just eating. It also affects behaviour and emotional wellbeing and the overall daily experience of the animal. Can you explain to me maybe how chronic dental pain affects behaviour and also the literature tells us something about the impact of quality of life? Can [00:17:00] you mention the paper you've just published as well? Jen Mathis: There's a systemic relationship between things going on in the mouth and changes in the body. With pain there's the emotional component, there's the fear component, there's an anxiety component. The easiest one for me to notice is orthodontic cases in puppies where there should be no pain in a puppy elsewhere. They're so mouth shy because the most common reason is a mandibular canine poking into the palate and it may not have gone through the palate, but it still is like having a rock in your shoe all the time. When we do orthodontics in veterinary medicine, it's not for cosmetic reasons. It's for painful reasons. They don't have to have a perfect mouth, they just have to have a functional bite without pain. Those are the dogs that get mouth shy and don't want you to look at it. A lot of times we'll look at one side that is normal and aligned correctly, and we'll look at it the other side. They won't let you look at it, and that becomes an emotional learned or chronic response to what's been happening. [00:18:00] Studies show patients with added fear, anxiety, and stress, which we're gonna talk about a little bit anaesthesia with dentistry, I believe, and I wanted to bring that up now in the component that fear, anxiety, and stress coming into the office actually can make it harder, in a way, for patients to go under anaesthesia. In other words, sometimes we need more drugs to overcome that fear response because anaesthetic planning for veterinary patients involves pain management as well, and make sure you're affecting all the different receptors. In that paper that I published, we referenced multiple different articles that showed somewhere between a 17 and 31% reduction in MAC, which is the alveolar concentration or the inhaled anaesthetic need when they were premedicated with gabapentin and or trazodone. In other words, we have taken away some of that fear component, which also can be the emotional component that involves the pain responses [00:19:00] as well. So they won't be as quite as heightened. David Clarke: Interesting topic regarding puppies 'cause I find that when they come into the clinic, the owners often say, oh, they don't seem to be in pain, which makes me think animals are mask pain really well. They do resist you closing their mouth and everyone thinks, oh, they're just being a naughty puppy. But actually they're probably in a lot of pain. So the owners don't see anything being wrong and the animals are masking their pain. Do you have any strategies maybe for communicating oral pain and welfare concerns to the owners when symptoms aren't obvious? Jen Mathis: It's a little hard because they may not believe you. Our patients can't speak. We need to be an advocate for them as veterinarians. We shouldn't say. I think it's okay to wait. A 2019 study on 2 million dogs showed that those that had annual anaesthetic dental procedures live 20% longer than those that had no dental procedures or irregular dental procedures. Now, that is not a [00:20:00] direct correlation because it was just looking at statistics on those patients and there's so many compounding factors, but that does imply because of the systemic health risks that we know that we can improve upon, that we can improve those things related to the systemic impact of dental disease as well. If we tell owners their pet needs a dental procedure every year, it's set the standard. In the meantime, active home care, daily wipes or brushing, shows a fourfold improvement over passive dental home care. But if you just clean the teeth at home with brushing, you're not really seeing the two thirds of each tooth underneath the gum line. For which three out of every four pets have hidden problems, and 42% have at least one visually normal tooth with a problem on x-ray. David Clarke: Delaying dental treatment must have serious welfare concerns. Can you mention maybe some of the key risks of postponing pain then? Jen Mathis: Well there's a lot of risk because again, there's a systemic [00:21:00] relationship between oral health and how things go along in the body. 1996 papers show the association of periodontal disease and biologic lesions in multiple organs, there are systemic effects of chronically infected oral cavity of the dog. In a 2005 paper, there's periodontal disease burden and the pathological changes in the organs of dogs. There's some definite relationships there. That was also shown in a 2008 paper. And then 2011, there's association of periodontal disease with systemic health indices. A lot of 'em were evaluated, specifically C-reactive protein, so creatinine, a kidney value, and C-reactive protein, both decrease after periodontal therapy. So basically patients with kidney issues will have some improvement. Doesn't mean they shouldn't have a dental procedure. In fact, the fluids given during procedures can help flush their system out. Periodontal disease can be a risk factor for chronic kidney disease. As periodontal disease scores increased chronic kidney [00:22:00] disease and cystitis incidents increase, and all of these are different papers. There's a relationship between chronic inflammation and secondary kidney scarring resulting in decreased function over time. So lots of different papers on that. There's generalised bacteremia causing cholestasis in dogs, so there can be some liver changes, but they're not quite as impactful. Meaning the liver is a very regenerative organ in general, but you can still help things when you keep the mouth healthy. And then for the heart evaluation they have shown in 2006 the echocardiographic alterations in periodontal disease in dogs. There's a clinical study showing the changes there. There's one dog that had mitral valve endocarditis after a dental prophylaxis. It doesn't happen with all of them by any mean, but there are increases in AV valve changes with periodontal disease, and it's not a direct relationship, but there is a sixfold higher risk for endocarditis when they compared patients that had stage three bone [00:23:00] loss beyond 25% versus those that were unaffected. And so if you have some bone loss, they're actually a sixfold higher risk for endocarditis. So there's a lot of different things and then they suspect there's relationship of periodontal disease to an induced chronic inflammatory state, and there's an increased inflammatory state with having increased incidence of oral cancers. It's hard to make it cause and effect because the body is so dynamic and there's so many things and factors at play but there's definitely a systemic relationship. So that was a really long answer to a really short question. David Clarke: No, no, it's good. It really just highlights how serious there are systemic effects when you've got a local disease. But on the same topic, analgesia is really important for our, our patients. Multimodal anaesthetic plans are important before and after dentistry procedures. Maybe you could talk about how multimodal anaesthetic and analgesic plans improve welfare? Jen Mathis: The fear component or [00:24:00] anxiety component can amplify a pain response that may not really be there. And so if we can minimise the anxiety component, we can help with that, and that's the most common done in the home period. Maropitant is a substance P inhibitor, and it is labeled for anti-nausea, but because it works with substance P, which does affect pain, it's just not a standalone pain modality. But it's been shown in studies that patients that received maropitant had better anaesthetic recoveries, return to normal after anaesthesia. I'm always using that in the pre-procedure phase. I'll have owners give it orally the night before. Other times we give it an hour before premedications. And then when we consider each patient, we wanna think about each patient and what is the problem going on? Is it just periodontal disease, which is the most common? Then I definitely need local blocks [00:25:00] before I would do any oral surgery, but it might be that there's a tiny little mass. That might mean that I have to cut into the jaw. Now I know I'm probably entering the mandibular canal. I have to think about what procedure I might have to do so I can prevent pain instead of chase after it. And so when I design my pre medications, I'm thinking about what I might need to do. Will I possibly need a continuous rate infusion, a CRI, during the procedure? It's not a cookbook where you just have a recipe and you just read it off. I want to tailor it to each patient, but all of those components work at different receptors. And so when you have a more even balanced everyone, everything, working different places, you get the better outcome. I like to think of it like a stool. If you have a chair you're sitting on, you might have a stump. A stump could have like a angle or cut out of it, and you might lean to the side. Or it could be more like a unicycle where you just sit there. But if it's a [00:26:00] stump, it's one big fat leg. That's one massive amount of drug to treat that pain. Or if we have a two legged stool, we're likely to very easily tip. If we have a three legged stool, we can be good, but one of them could be short or start to change and will fall to a side. Four legged stool, we get a lot more stability and then fives. If one of those five little legs of a stool is missing, the other four will be fine. You really don't need it. And so the more things you have gives you the best outcome, more stability. If you forget a drug you might tip a little versus falling off your stool. That's the easiest way to think about it, in my opinion. David Clarke: Well, one thing I learned just then is I have to change all the clinic stools. That is a brilliant analogy. Is there one practical thing that a veterinarian could start doing tomorrow that's gonna like immediately improve detection, management of oral pain? Jen Mathis: You need to tell your clients, your dog needs to have an anaesthetic dental procedure every year. Or cat, same thing. Same rule. It's hiding and you won't know it. [00:27:00] We are, as veterinarians, are kind of our own worst enemy at basically playing it down. Well, you should think about it. You have an optional dental procedure. Pets with the anaesthetic dental procedures live longer. Be a patient advocate, explain that to the client. My other little trick for general practice, I used to work at general practice before I did just exclusively specialty, but we do use OraStripdx and if you're worried that the clients don't believe there's a problem and they wanna know if there's gonna be bone loss around teeth, and it doesn't count for endodonic disease that may not show up radiographically, but won't probably show up on this OraStrip test. But it's an awake test. You just wipe on the gum line. If there's any yellow color, there's, depending which part of the quick study you look at, essentially an 80 to a hundred percent chance that there is bone loss around teeth and it's unrelated to the level of calculus. So they could have low calculus or no visible calculus and have [00:28:00] tons of bone loss, or they can have a ton of calculus and have no change on the  OraStrip meaning it's calculus heavy, but that doesn't mean it's caused bone loss yet. The OraStripdx test is testing for the presence of bacterial thiols, which relates to bone loss around teeth. So that's another trick if you're not sure. Since we're on tricks, I'll tell you one more I'd like to do for general practice. How many people have cotton ball jars or treat jars or something like that in their exam room? Right. A lot probably. Take your clipboard and you cover up that jar about at least two thirds and now you tell the client to tell you how many or how full is this jar? Or what's it look like in this jar? The clipboards covering it up, you can't see it. So if they can't tell you, then that's exactly what I can say about what's going on in in the tooth. Until we could take dental radiographs, there's probably something hiding that your pet is not showing you. I can't tell you what's going on with that tooth. I think there's a problem. There's a 72 to [00:29:00] 86% chance there's a problem. We should go look. Jim Berry: Thanks for joining us on the WSAVA Podcast, where we are transforming care, one episode at a time. We hope today's discussion was helpful wherever you are in the world. You'll find more information and further resources on the topics discussed in the show notes and we look forward to sharing our next conversation with you very soon.