B. Monteiro1; P. Steagall2
The pain experience is a combination of sensory and emotional components. Pain causes fear, stress and anxiety, negatively impacting quality of life. It also delays recovery and induces behavioral changes that affect the owner-companion animal bond.1 Dental and oral diseases are by far the most common conditions seen in small animal practice. They can produce significant pain, as well as localized and potentially systemic infection.2 Indeed, severe pain and inflammation might further impact nutrition and feeding behavior. Treatment of periodontal disease often involves general anesthesia and dental extractions.3
Recently, extensive guidelines on the management of dental disease in dogs and cats have been reported.2,3 These documents highlight the importance of adequate pain management and the mandatory use of general anesthesia for appropriate dental treatment.
The literature specific to dental pain is quite limited in veterinary medicine. Nevertheless, recent studies have shed some light into the subject. For example, in a study involving cats with minimal or severe periodontal disease, several parameters were evaluated including pain scores, analgesic requirements and food intake before and after dental treatment. Cats were evaluated under general anesthesia and treatment was performed according to what was clinically recommended; they were evaluated for up to 6 days. Pain scores were significantly increased in cats with severe disease when compared with baseline and with cats with minimal disease. Prevalence of rescue analgesia was significantly higher in severe (91.7%) than minimal disease (0%). Pain scores and frequency of rescue analgesia were significantly correlated with the number of tooth extractions, gingival and calculus index. Finally, food intake was significantly lower in cats with severe dental disease.4 Those authors highlighted the need for long-term analgesia after dental extractions in cats with severe oral disease. Furthermore, when the behaviors of cats with minimal and severe dental disease were compared using video-analysis before and after treatment, cats with severe disease showed particular behaviors when compared with those with minimal disease. They spent significantly less time sitting and paying attention to surroundings, and significantly more time laying down, at the back of the cage or curling the tail.5 Pain scales such as the Glasgow feline composite measure pain scale can be used to help in the assessment of postoperative pain after dental treatment and extractions in cats. Detailed information of the use of these scales is available elsewhere.6
The prevalence of chronic pain in cats due to periodontal disease is unknown, but it is believed to be quite prevalent if one considers the frequency at which these are diagnosed in practice. It can involve periodontal disease, but also tumors affecting the oral cavity, for example.7 In dogs, a few studies are also available. For example, a study designed to evaluate the analgesic efficacy of local anesthetic techniques in models of oral pain in dogs revealed that the addition of buprenorphine to bupivacaine may extend the duration of analgesia during regional anesthetic blocks.8 In another study, the efficacy and safety of deracoxib administered for 3 days was compared with placebo for the control of postoperative pain and inflammation associated with dental surgery in dogs. Dogs were evaluated prior to and after surgery using a modified Glasgow Composite Pain Scale (mGCPS). Pain scores were lower in dogs treated with deracoxib than placebo. Four out of 27 deracoxib-treated dogs (14.8%) were rescued compared to 20 out of 30 placebo-treated dogs (66.7%).9 This study highlights the importance of long-term analgesic requirements in dogs undergoing dental treatment. When it comes to chronic pain, a recent survey involving veterinarians from the UK revealed that dental pain is considered an important cause of chronic pain in dogs.10 They can also be affected by malignant and non-malignant diseases of the oral cavity causing chronic pain. The treatment of dental pain is multimodal and involves pharmacological and non-pharmacological techniques. In the pharmacological treatment of acute pain, local anesthetic techniques, non-steroidal anti-inflammatory drugs and opioids should always be considered. In the pharmacological treatment of chronic pain, non-steroidal anti-inflammatory drugs as well as centrally acting analgesics, such as gabapentin, amitriptyline and tramadol (cats only), might be considered. This lecture will improve your knowledge on dental pain and will ultimately impact how you manage these patients in the clinic to provide them with better hospital experiences and better outcomes.
1. Mathews K, Krone P, Lascelles D, Nolan A, Robertson S, Steagall P, et al. Guidelines for recognition, assessment and treatment of pain: WSAVA Global Pain Council members and co-authors of this document. 2014;55(6):E10–68.
2. Niemiec B, Gawor J, Nemec A, Clarke D, Tutt C, Gioso M, et al. World Small Animal Veterinary Association Global Dental Guidelines [Internet]. 2018 [cited 2018 Apr 14]. Available from: www.wsava.org/WSAVA/media/Documents/Guidelines/Dental-Guidleines-for-endorsement_0.pdf
3. Bellows J, Berg ML, Dennis S, Harvey R, Lobprise HB, Snyder CJ, et al. 2019 AAHA Dental Care Guidelines for Dogs and Cats. J Am Anim Hosp Assoc [Internet]. 2019 Mar [cited 2019 Mar 28];55(2):49–69. Available from: www.ncbi.nlm.nih.gov/pubmed/30776257.
4. Watanabe R, Doodnaught G, Proulx C, Auger J, Monteiro B, Dumais Y, et al. A multidisciplinary study of pain in cats undergoing dental extractions: a prospective, blinded, clinical trial. 2019;1–13.
5. Watanabe R, Frank D, Steagall P. Pain behaviors before and after treatment of oral disease: preliminary results. In: 8th Annual Congress of Asian Society of Veterinary Surgery. Taichung, Taiwan; 2018.
6. Steagall PV, Monteiro BP. Acute pain in cats: recent advances in clinical assessment. J Feline Med Surg. 2019;21(1):25–34.
7. Monteiro B, Lascelles BDX. Assessment and recognition of chronic (maladaptive) pain. In: Steagall PVM, Robertson SA, Taylor PM, editors. Feline Anesthesia and Pain Management. 1st. Hoboken, NJ: Wiley/Blackwell (10.1111); 2017;241–56.
8. Snyder LBC, Snyder CJ, Hetzel S. Effects of buprenorphine added to bupivacaine infraorbital nerve blocks on isoflurane minimum alveolar concentration using a model for acute dental/oral surgical pain in dogs. J Vet Dent [Internet]. 2016 Jun 6 [cited 2019 Mar 28];33(2):90–6. Available from: http://journals.sagepub.com/doi/10.1177/0898756416657232
9. Bienhoff SE, Smith ES, Roycroft LM, Roberts ES. Efficacy and safety of deracoxib for control of postoperative pain and inflammation associated with soft tissue surgery in dogs. Vet Surg [Internet]. 2012 Jan [cited 2019 Mar 28];41(3):n/a-n/a. Available from: www.ncbi.nlm.nih.gov/pubmed/22225463
10. Bell A, Helm J, Reid J. Veterinarians’ attitudes to chronic pain in dogs. Vet Rec. 2014;175(17):428.