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Periodontal disease is one of the most common diseases affecting dogs, with a reported prevalence of at least 80% in dogs over 3 years of age. However, there is a lack of studies regarding dog owners' assessment of their dog's dental health, and whether they perceive clinical signs often associated with periodontal disease, i.e., dental calculus, halitosis or mobile or lost teeth. A validated questionnaire survey was distributed to all Swedish dog owners with email addresses in the national registry (n = 209,263). The response rate was 32%. The survey questions concerned opinions and practices regarding canine dental health, including assessment of dental health parameters and dog owners' ability to examine their dog's mouth. A construct (α = 0.76) was used to investigate dog owners' assessed symptoms of their dog's dental health in relation to background factors. Half of the respondents rated their dog's dental health as very good. However, one in four dog owners experienced difficulties when inspecting the dog's teeth. The most common reason for this difficulty was stated to be an uncooperative dog. Almost half of the dog owners reported halitosis to some degree in their dog, and almost four in ten owners reported dental calculus. One in eight dogs had been previously anesthetized for dental cleaning, and one in 12 dogs had experienced problems with gum disease, according to the owners. Owners' assessment varied significantly with the dog's age, weight, breed, breed group, sex, and concurrent disease. Owner-related factors that influenced the assessment of the dog's dental health were age, gender, education, county (urban/rural), and whether they were breeders or not. Dog owners with smaller dogs, older dogs and certain breeds predisposed to periodontal disease assessed their dog's dental health as worse than their counterparts, which is in agreement with previously reported higher prevalence of dental disease in these groups. This indicates that dog owners are able to perform relative assessment of their dog's dental health status. Our results also highlight the need for routine professional assessment of periodontal health, as well as education of dog owners and training of dogs to accept dental care procedures.
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ORIGINAL RESEARCH
published: 09 June 2020
doi: 10.3389/fvets.2020.00298
Frontiers in Veterinary Science | www.frontiersin.org 1June 2020 | Volume 7 | Article 298
Edited by:
Ana Nemec,
University of Ljubljana, Slovenia
Reviewed by:
Henriëtte Booij-Vrieling,
Utrecht University, Netherlands
Margherita Gracis,
Istituto Veterinario di Novara, Italy
*Correspondence:
Karolina Brunius Enlund
karolina.enlund@slu.se
Specialty section:
This article was submitted to
Veterinary Dentistry and
Oromaxillofacial Surgery,
a section of the journal
Frontiers in Veterinary Science
Received: 19 March 2020
Accepted: 04 May 2020
Published: 09 June 2020
Citation:
Enlund KB, Brunius C, Hanson J,
Hagman R, Höglund OV, Gustås P
and Pettersson A (2020) Dog Owners’
Perspectives on Canine Dental
Health—A Questionnaire Study in
Sweden. Front. Vet. Sci. 7:298.
doi: 10.3389/fvets.2020.00298
Dog Owners’ Perspectives on Canine
Dental Health—A Questionnaire
Study in Sweden
Karolina Brunius Enlund 1,2
*, Carl Brunius 3, Jeanette Hanson 1, Ragnvi Hagman 1,
Odd Viking Höglund 1, Pia Gustås 1and Ann Pettersson 1
1Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden, 2Anicura Albano Animal
Hospital, Stockholm, Sweden, 3Department of Biology and Biological Engineering, Food and Nutrition Science, Chalmers
University of Technology, Gothenburg, Sweden
Periodontal disease is one of the most common diseases affecting dogs, with a reported
prevalence of at least 80% in dogs over 3 years of age. However, there is a lack of
studies regarding dog owners’ assessment of their dog’s dental health, and whether they
perceive clinical signs often associated with periodontal disease, i.e., dental calculus,
halitosis or mobile or lost teeth. A validated questionnaire survey was distributed to
all Swedish dog owners with email addresses in the national registry (n=209,263).
The response rate was 32%. The survey questions concerned opinions and practices
regarding canine dental health, including assessment of dental health parameters and
dog owners’ ability to examine their dog’s mouth. A construct (α=0.76) was used to
investigate dog owners’ assessed symptoms of their dog’s dental health in relation to
background factors. Half of the respondents rated their dog’s dental health as very good.
However, one in four dog owners experienced difficulties when inspecting the dog’s
teeth. The most common reason for this difficulty was stated to be an uncooperative
dog. Almost half of the dog owners reported halitosis to some degree in their dog, and
almost four in ten owners reported dental calculus. One in eight dogs had been previously
anesthetized for dental cleaning, and one in 12 dogs had experienced problems with gum
disease, according to the owners. Owners’ assessment varied significantly with the dog’s
age, weight, breed, breed group, sex, and concurrent disease. Owner-related factors that
influenced the assessment of the dog’s dental health were age, gender, education, county
(urban/rural), and whether they were breeders or not. Dog owners with smaller dogs,
older dogs and certain breeds predisposed to periodontal disease assessed their dog’s
dental health as worse than their counterparts, which is in agreement with previously
reported higher prevalence of dental disease in these groups. This indicates that dog
owners are able to perform relative assessment of their dog’s dental health status.
Our results also highlight the need for routine professional assessment of periodontal
health, as well as education of dog owners and training of dogs to accept dental
care procedures.
Keywords: dog, survey, dental health, periodontal disease, breeds
Enlund et al. Canine Dental Health
INTRODUCTION
Although one of the most common diseases affecting dogs, with a
reported prevalence of 80–89% in dogs over 3 years of age (14),
periodontal disease is often overlooked and may therefore be
inadequately treated and prevented (5). Periodontal disease is an
inflammatory disease affecting the tooth supporting tissues which
may lead to progressive tissue and tooth loss (6). Studies have
shown an increased prevalence of periodontal disease in smaller
dogs, and the severity of the disease in general increases with
age (1,7,8). Today, the potential systemic effects of periodontal
disease is of growing concern and a multitude of studies have
been presented within human medicine, identifying associations
between periodontal disease and other diseases, such as diabetes
mellitus, cardiovascular disease, and immunological disease (9,
10). In veterinary medicine, however, few studies have as yet been
published on the topic and some have shown conflicting results,
indicating the need for further standardized prospective studies
within this field (5,1113).
Owners’ different ability to examine their dog’s mouth and
their knowledge concerning normal and pathologic dental
conditions may considerably influence their assessment of their
pet’s dental health. Dog owners may or may not recognize
clinical signs of periodontal disease, e.g., halitosis, gingival
inflammation and recession, and tooth mobility or tooth loss.
The presence of dental calculus, visible to dog owners, is not
indicative of periodontal disease per se, although it may indicate
poor dental hygiene. Experts agree that a thorough dental
exam, including periodontal probing of all tooth surfaces, and
intraoral radiographic examination, is necessary to assess clinical
attachment loss, i.e., degree of periodontal disease. Consequently,
even veterinarians may be unable to assess dental health properly
during the clinical examination of a non-anesthetized animal (5).
This highlights the need for professional dental assessment under
anesthesia on a regular basis for all dogs.
Daily tooth brushing is considered the gold standard for
prevention of periodontal disease development and progression
(1418). Compliance to the recommendation of daily tooth
brushing in veterinary patients is low (19). This may, in part, be
explained by a lack of knowledge regarding dental disease (19),
and an important factor to increase compliance may thus be to
increase awareness of clinical signs of disease among dog owners.
Additionally, dental home care is not possible without the dog
owner being able to handle the dog’s mouth, which requires a
certain amount of skill and training of both dog and owner.
However, studies regarding whether, and how, dog owners assess
their dog’s dental health are lacking.
Within the framework of a nationwide survey on canine
dental home care (19,20), we have investigated canine dental
health from a dog owner perspective. If properly constructed
and validated, questionnaire surveys provide a useful method
for evaluating attitudes, opinions and practices on specific
topics (2022).
The aim of the present study was to investigate dog owners’
general opinions, as well as their assessment, of their dog’s dental
health. Additionally, associations between perceived dental
problems and specific non-dental chronic diseases were explored.
To our knowledge, this is the first survey presented with
this objective.
MATERIALS AND METHODS
Study Design
In order to investigate dog owners’ opinions and assessment
of their dog’s dental health, and perceived dental problems
and specific non-dental chronic diseases, a questionnaire survey
to dog owners was analyzed. This was part of a large study
including questionnaire surveys to dog owners, veterinarians
and veterinary nurses, which were constructed and validated
according to survey methodology guidelines, as described
elsewhere (19,20). The target group consisted of all registered
dog owners in Sweden, 607,610 individuals. Sample frames were
dog owners with email addresses registered with the Swedish
Board of Agriculture (13 March 2017) and email addresses
registered with the Swedish Kennel Club (9 February 2017),
giving in total 209,263 email addresses of dog owners.
The questionnaire survey was adapted for use on personal
computers, tablets and smartphones, using the web platform
Netigate (Netigate AB, Stockholm, Sweden). The questionnaires
were distributed and reminders were sent to non-responders
after 8 and 17 days. Data collection started on 31 March and
was completed on 30 April 2017. Anonymous responses were
collected and the questionnaire could only be answered once
per link. If the household owned more than one dog (23%
owned more than one dog, personal communication, Magnus
Kindström, Swedish Board of Agriculture, 28 August, 2017), the
respondent was asked to choose one of them and answer for the
same dog throughout the survey (20). The study was approved by
the Regional Ethical Review Board in Uppsala (Dnr 2017/035).
The total length of the questionnaire for dog owners ranged
from 54 to 68 questions for the individual respondents depending
on their answers. The questions were mainly closed, i.e., with
fixed response options, and both nominal and ordinal data were
collected (20). Twelve questions [Questions 5, 6, 7, 18, 19, 20,
23, 24, 25, 26, 28, 29 (20)] concerned owners perception of the
dog’s dental and general health. In particular, questions 5, 6, and
7 relate to dog owners’ general opinions on the dental health of
their dog, and questions 19 and 20 to their assessment of the
dental health of their dog, questions 18, 23, 24, 25, and 26 to their
dogs dental health, and questions 28 and 29 to general health and
specific non-dental chronic diseases.
Statistical Analysis
Responses to survey questions are reported as percentages
rounded to the nearest first decimal, and may consequently not
sum up to exactly 100%.
Pretreatment of data, including identification and validation
of constructs, is described in detail elsewhere (20). In brief,
exploratory factor analysis (EFA) was performed on random
half-splits of numeric and ordinal non-sociodemographic data
to identify factors, which were confirmed in the other half-split
using confirmatory factor analysis (CFA). Final construct scores
were extracted from CFA on all data using variables selected
from the EFA/CFA validation procedure. The construct used in
Frontiers in Veterinary Science | www.frontiersin.org 2June 2020 | Volume 7 | Article 298
Enlund et al. Canine Dental Health
this study “Dog owners’ assessed symptoms of their dog’s dental
health” reflected core concepts regarding canine dental health
and these are illustrated in Table 1.
All statistical analysis was performed in the R open source
statistical software v 3.5.1 (23). Overall significance of fixed
factors in linear mixed modeling was assessed by type III tests
and using Tukey adjustment for pairwise comparisons. Results
are reported as least squares means with 95% CI. Results from
logistic regressions are reported as odds ratios with 95% CI.
The breeds were grouped into 10 breed groups as used by the
FCI (Federation Cynologique Internationale) (24) as well as the
Swedish Kennel Club, for further analysis (Table 2).
The Dental Health construct was analyzed by linear mixed
modeling using the R “glm” function. Dog weight group, sex and
breed group, reported diseases (Figure S1d) and owner gender,
level of education, county (urban vs. rural), employment, medical
profession (assistant nurse, nurse, physician, dental nurse, dental
hygienist, dentist, animal caretaker, veterinary nurse/technician,
veterinarian) and breeder status were included as fixed factors. In
addition, dog and owner year-of-birth were added as covariates.
To investigate the association between Dental Health and breeds,
a linear model was used which included dog breed and sex
as well as owner gender, level of education, county (urban vs.
rural), employment, medical profession and breeder status as
fixed factors, and dog and owner year-of-birth as covariates.
The questions “How would you appraise your dog’s general
health?” (Q28), “How important is it for you that your dog has
good dental health?” (Q6) and “How easy or difficult is it for you
TABLE 1 | Questions included in the construct: “Dog owners’ assessed
symptoms of their dog’s dental health” (α=0.76) (20).
How would you appraise your dog’s dental health? (Q5)
Has your dog been anesthetized at a veterinary clinic to clean the
teeth/remove dental calculus? (Q23)
Has your dog had problems with gum disease or loose teeth? (Q24)
Does your dog have bad breath? (Q25)
Does your dog have dental calculus at the moment? (Q26)
How would you appraise your dog’s general health? (Q28)
Numbers in parentheses correspond to the number of the question in the full survey (20).
TABLE 2 | Breed groups, adapted from FCI (Federation Cynologique
Internationale) (24).
Group 1 Sheepdogs and Cattledogs (except Swiss Cattledogs)
Group 2 Pinscher and Schnauzer—Molossoid and Swiss
Mountain and Cattledogs
Group 3 Terriers
Group 4 Dachshunds
Group 5 Spitz and primitive types
Group 6 Scent hounds and related breeds
Group 7 Pointing Dogs
Group 8 Retrievers—Flushing Dogs—Water Dogs
Group 9 Companion and Toy Dogs
Group 10 Sighthounds
to inspect (look at) all of your dog’s teeth?” (Q19) were analyzed
by ordinal logistic regression using the R’polr’ function from the
“MASS” package and with the same fixed factors and covariates.
RESULTS
The total number of respondents was 66,434, corresponding to
a response rate of 32%. After removing individuals with >20%
missing data among selected background questions, there were a
total of 59,978 completed individual responses (20).
Background characteristics of dog owner respondents and
their dogs are described in detail elsewhere (19). In brief, the dogs
were 4.9 ±3.5 years of age (mean ±SD). All breed groups were
represented. Breed group 8 (Retrievers, Flushing Dogs, Water
Dogs) was the largest (18%), followed by dogs of mixed breed
(15%), and Group 9 (Companion and Toy Dogs) (15%). German
Shepherd Dog, Labrador Retriever and Golden Retriever were the
most common pure breeds, comprising more than 10% of all dogs
(Figure S1e). One-third (33%) of dogs weighed under 10 kg and
the majority (78%) of all dogs were sexually intact (19).
Dog owners were 49.9 ±13.4 years of age (mean±SD), 74.8%
were women, 24.6% were men and 0.7% preferred not to answer
the question or defined themselves as other. Forty six percent of
all dog owners lived in urban counties (Stockholm, Skåne, Västra
Götaland). Seventy percent were employed or self-employed.
Forty nine percent had studied at a university and 23% reported
that they worked within a healthcare profession. Moreover, one
in twelve (8%) was a dog breeder (19).
Survey results are summarized in Tables 3,4and Figures 13.
Seventy eight percent of owners perceived their dog’s general
health as very good (Table 3), and half (50%) stated their dog’s
dental health as very good (Figure 1). Of the owners of dogs over
3 years of age, 38% rated dental health as very good. The owners
of dogs in breed group 9 (Companion and Toy Dogs) rated their
dog’s general health lowest, and owners of dogs in breed group
7 (Pointing Dogs) highest. Survey participants living in urban
counties and owners of younger dogs rated their dog’s general
health as better than those living in rural counties and owning
older dogs (Figure S1a).
Among breeds with 100 respondents per breed, owners of
Briard (78%), Dobermann (77%), and Giant Schnauzer (76%)
were most likely to answer that their dog had very good dental
health. The owners of a Prazský krysarík (19%), Chinese Crested
Dog (25%), Pomeranian (25%), Italian Greyhound (25%), and
Chihuahua (27%) dogs were least likely to report very good dental
health. The owners of Pug (34%), Chihuahua (21%), Yorkshire
Terrier (17%), Pomeranian (16%) and Papillon (16%) dogs were
most likely to report it very difficult to inspect the dog’s teeth.
Four out of five (80.2%) owners considered the dog’s dental
health to be very important (Table 4). Owners of dogs over 30 kg
considered the dental health of their dog more important than
owners of smaller dogs did. Men were less likely than women
(OR =0.55; 95%CI: 0.53–0.58) to consider dental health in their
dog important. Dog breeders and owners from urban counties
considered dental health more important than owners from rural
counties did, and dog owners with a higher education level
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Enlund et al. Canine Dental Health
TABLE 3 | Results from the survey.
Has your dog been anesthetized at a
veterinary clinic to clean the
teeth/remove dental calculus? (Q23)
No Yes, once Yes, several times Don’t know
51,789 (86.3%) 5,217 (8.7%) 2,620 (4.4%) 352 (0.6%)
Has your dog had problems with gum
disease or loose teeth? (Q24) (Does
not apply to puppy teeth)
No Yes, has had teeth extracted
or lost teeth
Yes, but has not had
any teeth extracted
Don’t know
55,033 (91.8%) 3,900 (6.5%) 729 (1.2%) 316 (0.5%)
Does your dog have bad breath?
(Q25)
No, never Yes, sometimes Yes, often Yes, always Don’t know
31,033 (51.7%) 24,427 (40.7%) 2,961 (4.9%) 1,275 (2.1%) 282 (0.5%)
Does your dog have dental calculus
at the moment? (Q26)
No Yes, a little Yes, a moderate amount Yes, a lot Don’t know
31,159 (52.0%) 18,753 (31.3%) 2,925 (4.9%) 673 (1.1%) 6,468 (10.8 %)
How would you appraise your dog’s
general health? (Q28)
Very poor Fairly poor Neither good nor bad Fairly good Very good Don’t know/Unable to
judge
196 (0.3%) 565 (0.9%) 1,229 (2.1%) 11,102 (18.5%) 46,715 (78.0%) 102 (0.2%)
Questions from the construct: “Dog owners’ assessed symptoms of their dog’s dental health.” Percentages are rounded to the nearest first decimal. Number in parenthesis after the
question corresponds to the number of the question in the full survey (20).
TABLE 4 | Results from the survey.
How important is it for you that your
dog has good dental health? (Q6)
Not at all important Of minor importance Fairly important Very important Don’t know
18 (0.0%) 267 (0.4%) 11,354 (18.9%) 48,089 (80.2%) 250 (0.4%)
What do you consider to be important
for good dental health in dogs? (Q7)
Good general health 43 (0.1%) 197 (0.3%) 8,319 (14.5%) 48327 (84.4%) 342 (0.6%)
The dog’s breed/heredity 1,230 (2.2%) 5,337 (9.3%) 23,400 (41.0%) 18,033 (31.6%) 9,093 (15.9%)
When you clean your dog’s teeth at
home, does the gum ever bleed?
(Q18) (Only visible to respondents
who brush/clean their dog’s teeth)
No, never Yes, sometimes Yes, often Yes, always Don’t know
19,171 (60.6%) 10,107 (32.0%) 684 (2.2%) 165 (0.5%) 1,489 (4.7%)
How easy or difficult is it for you to
inspect (look at) all of your dog’s
teeth? (Q19)
Very easy Fairly easy Fairly difficult Very difficult Don’t know
22,146 (36.9%) 22,897 (38.2%) 11,399 (19.0%) 3,270 (5.5%) 266 (0.4%)
What difficulties do you experience
when inspecting your dog’s teeth?
(Q20) Several options can be
specified (Only visible to respondents
who answered “Fairly” or “Very
difficult” on Q19)
The dog is in pain
The dog gets angry
The dog doesn’t want to
Own impaired physical ability
I do not know how to do it
Technically/practically difficult to perform
Don’t know
Other reason
82 (0.6%)
1,103 (7.5%)
11,609 (79.1%)
303 (2.1%)
1,318 (9.0%)
4,642 (31.6%)
139 (0.9%)
400 (2.7%)
Questions not included in the construct “Dog owners’ assessed symptoms of their dog’s dental health.” Percentages are rounded to the nearest first decimal. Number in parenthesis
after the question corresponds to the number of the question in the full survey (20).
considered dental health of their dog less important than owners
with a lower education level (Figure S1b). 84.4% of dog owners
regarded good general health as very important for good dental
health, and the dog’s breed (heredity) was considered to be very
important by 31.6% of dog owners (Table 4).
One in four (24.5%) owners sometimes or always experienced
difficulties when inspecting the dog’s teeth (Table 4), and the
smaller the dog, the more difficult (Figure S1c). Breeders and
owners from urban counties found it easier to inspect their
dog’s teeth than owners from rural counties. The owners of dogs
in breed group 9 (Companion and Toy Dogs) found it most
difficult, and owners of dogs in breed group 4 (Dachshunds) and
7 (Pointing Dogs) found it least difficult to inspect the dog’s teeth
(Figure S1). The most common reasons for these difficulties were
stated as an uncooperative dog (79.1%) and practical/technical
difficulties (31.6%) (Table 4).
47.7% of the dog owners reported halitosis to some degree,
and 37.3% of owners reported the presence of dental calculus.
Of the owners who cleaned their dog’s teeth (19), 34.7% stated
occasional oral bleeding (Table 4). 13.1% of dogs had been
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Enlund et al. Canine Dental Health
FIGURE 1 | How would you appraise your dog’s dental health?
previously anesthetized for dental cleaning, and 7.7% of dogs had
experienced problems with gum disease/mobile teeth, according
to the owner (Table 3).
Associations between background characteristics of dogs and
dog owners, and dog owners’ assessed symptoms of their dog’s
dental health are shown in Figures 23and in Figure S1f.
Reported construct scores of “Dog owners’ assessed symptoms of
their dog’s dental health” were lower, indicating worse perceived
dental health, the smaller the dog was (Figure 2). The owners
(n>400 respondents/breed) of German Shepherd Dog, Flat
coated Retriever and Rottweiler had the highest scores in the
construct, reflecting a perceived better dental health than owners
of Chihuahua, Yorkshire Terrier and Chinese Crested Dog, who
had the lowest scores (Figure 3). Women perceived dental health
in their dog as worse than men did, and breeders perceived dental
health as better than their counterparts (Figure 2). Younger dog
owners and owners of older dogs perceived their dog’s dental
health as worse than their counterparts (Figure S1f).
The most common concurrent diseases, among the
alternatives provided in the questionnaire, were skin disease
(3.9%), and joint disease (3.7%) (Figure S1d). Concurrent
diseases reported by 100 dog owners were investigated
further and were associated with a more negative dental health
assessment, in particular for cardiac disease, renal disease and
hepatic disease (Figure 2).
Odds ratios for the association of dogs’/dog owners
background characteristics with dog owners’ rated general
health, stated importance of dental health, and stated difficulties
in inspecting the dog’s teeth, are shown in Supporting
Information (Figures S1a–c).
DISCUSSION
This study reports the results from a questionnaire to dog
owners regarding their dog’s dental health. The vast majority
of participating dog owners responded that the dental health
of their dog was important. In addition, the huge interest and
dedication of the respondents, with more than 66,000 individual
respondents and almost 9,000 free text comments, clearly showed
dog owners’ engagement in the dental health of their dog, which
was an important finding in itself.
General and Dental Health
Most dog owners, almost eight out of 10, regarded the general
health of their dog to be very good, while only half of the
dog owners perceived their dog’s dental health to be at the
same high level. One third of dog owners rated their dog’s
dental health as only fairly good, indicating that they had, in
fact, noted a deviation from an optimal situation. However, this
overall positive assessment of dental health is in contrast to
the veterinarians’ and veterinary nurses’ estimations of dental
problems as very or fairly common (19), and with the known high
prevalence of canine dental disease (13). Several explanations
for this discrepancy are possible. First, there is likely a lack of
knowledge among dog owners concerning periodontal disease
and its clinical signs. Also, there may be difficulties to thoroughly
examine the dog’s teeth, as reported in the present survey. Since
dogs do not often show apparent signs of dental discomfort,
owners are likely to underestimate dental problems as well as
their impact on general well-being. Furthermore, there is an
inherent lack of precision in the terminology. For example,
where an owner may observe a minor dental problem and assess
dental health as “Fairly good,” a veterinary health professional
may upon clinical examination find signs of periodontal disease.
Finally, anesthesia is required to fully examine a dog’s dental
status, including clinical attachment loss, which means that oral
examination in the awake animal may be insufficient in the
majority of cases for a full diagnosis.
The fact that more than one in four dog owners stated
that they did not know if breed was an important factor
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Enlund et al. Canine Dental Health
FIGURE 2 | Dog owners’ assessed symptoms of their dog’s dental health. Associations between background characteristics of dog/dog owner, and dog owners’
assessed symptoms of their dog’s dental health. Higher construct score represents a relatively better perceived dental health. Scores should only be compared within
figure. Note that negative scores do not automatically reflect a negative assessment of dental health.
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Enlund et al. Canine Dental Health
FIGURE 3 | Association of breeds with owners’ assessed symptoms of their dog’s dental health. Reported for breeds with 400 respondents. Higher construct score
represents a relatively better perceived dental health. Scores should only be compared within figure. Note that negative scores do not automatically reflect a negative
assessment of dental health.
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Enlund et al. Canine Dental Health
related to dental health, or stated that it was not important,
highlights a potential knowledge gap among dog owners, since
the predisposition of some breeds to periodontal disease is well-
known (2,2528).
Dog Owners Assessment of Their Dog’s
Dental Health
Discouragingly, as many as one in four dog owners experienced
difficulties when inspecting the dog’s teeth. If dog owners cannot
manage to examine the mouth properly, it is also likely that
tooth brushing is difficult or even impossible. The most common
reported reasons for these difficulties were uncooperative dogs
and practical/technical difficulties, highlighting the need for
early training of both dogs and owners in dental home
care routines.
In spite of the known high prevalence of canine dental
disease, only 13% of dogs in this study had been previously
anesthetized for professional dental cleanings and only 6% had
lost or extracted teeth, indicating a low number of dental
procedures having been performed in this study population.
This study is, to the authors’ knowledge, the first published
investigation on the proportion of privately owned dogs that
have undergone dental cleaning under anesthesia. In comparison,
despite anesthesia-free dentistry being strongly discouraged by
the veterinary dental community (5), we have previously reported
that more than 20% of the dog owners in our study population
reported the use of a dental scaler to remove calculus on a
non-anesthetized dog (19). Although the study population was
relatively young, with about 45% of dogs being 3 years old or
less (19), these findings in conjunction with the high reporting of
halitosis [which is most commonly caused by dental disease (29)],
suggest that what is presented at the clinic is only the tip of the
iceberg, leaving many dogs with untreated or incorrectly treated
dental problems.
We cannot know the actual amount of dental calculus in
the dogs participating in the study. However, almost four out
of ten dog owners made the assessment that their dog had
dental calculus to some degree (Table 3). It is more likely that
the amount of calculus is underestimated than overestimated.
In addition, it is remarkable that more than one out of ten
owners did not know if their dog had dental calculus. These
results are likely a consequence of dog owners’ lack of ability to
correctly identify dental calculus and also to properly inspect the
dog’s teeth.
Gingival bleeding is an indication of gingivitis in both humans
and in dogs. More than one third of dog owners reported
oral bleeding when brushing (Table 4), and a comparison with
previously published results (19) showed that brushing less
frequently is associated with increased risk of bleeding (χ2-test
p<2.2 ×10–16). Also considering that almost one third of
Swedish dog owners stated that they brushed more seldom than
once a week (19), the low frequency of brushing has likely led
to persistent gingivitis. No other questions regarding gingivitis
were included in the study, due to the risk of incorrect owner
assessment of gingival inflammation and/or recession.
The fact that owners’ perception of their dog’s dental
health varied with breed, age, and weight is in accordance
with the previously reported higher prevalence of periodontal
disease in smaller and older dogs as well as in particular
breeds (1,2,7,2528). A previous study in humans has
shown low reliability of self-evaluation of periodontal variables
(30). However, a significant positive correlation between dog
owners’ and veterinarians’ assessment of dental health, in non-
anesthetized dogs, was recently shown (31). Together, these
studies indicate that dog owners’ reports on perceived dental
problems are likely true, whereas non-reporting cannot be seen
as an absence of disease. Moreover, in the present study the
dog’s dental health was generally considered good, contrary
to the known high prevalence of dental disease reported
in other studies (13,7,8). The fact that one in four
dog owners experienced difficulties inspecting the dog’s teeth
may also contribute to the underreporting of problems. Our
conclusion is that owners seem capable of identifying dental
problems, although the true extent of dental disease is likely
underestimated.
Other Diseases
The survey also investigated owner-reported prevalence of
some common non-dental chronic diseases, known to have
immunological /inflammatory properties (Cushing’s disease,
Addison’s disease, hypothyroidism, skin disease/allergy,
osteoarthrosis) or to have more direct associations with
periodontal disease in humans and/or dogs (diabetes, cardiac
disease, hepatic disease, renal disease) (11,12,32,33). Especially,
owner-reported cardiac, hepatic and renal disease were
associated with worse assessed dental health. Dental health
may be affected by the concurrent disease or medication,
or problems may be acknowledged to a higher degree, for
example because of increased owner awareness. Associations
between worse periodontal health and numerous diseases
have also been found in humans. However, causality is not
evident and mechanisms describing the relationship between
general health and dental health remain to be elucidated
(9,10,34).
Strengths and Limitations
In order to ensure high data quality, it is essential to construct
surveys according to evidence based methods and validation
procedures. The construction and validation of the survey
used in this study have previously been presented in detail.
The validation further showed that the representatively of the
respondents was satisfactory overall (20). The large study sample
in this study constitutes a major strength, ensuring that the
obtained data are likely to give a correct reflection of the enquired
opinions and attitudes.
Despite meticulous efforts to avoid bias, questionnaire surveys
are inevitably susceptible to recruitment bias, social desirability
bias, and acquiescence bias. A potential risk is that respondents
may be more interested in the subject than the average
population. Further, misinterpretation of preformulated answers
is always a potential risk. As a part of the questionnaire
validation process, efforts were made to limit the use of
Frontiers in Veterinary Science | www.frontiersin.org 8June 2020 | Volume 7 | Article 298
Enlund et al. Canine Dental Health
vague response options such as “sometimes”/ “often” or “very
good”/“very poor.” In this study, however, the objective was
not to measure actual frequencies, but instead to examine
opinions, necessitating the use of the more vague response
alternative (20).
Clinical examinations were not performed and dental health
assessments made by the dog owners could, consequently, not be
validated. However, the construct had high internal consistency
and high reliability, as assessed by scientific and clinical experts
(20). In addition, the construct confirmed known associations
between dental health and dog breed, weight, and age, indicating
high construct validity (20).
Another limitation of the present study regarded the diagnosis
of non-dental diseases. Some of these (e.g., Cushing’s disease,
Addison’s disease, hypothyroidism) were likely based on the
actual diagnosis made by a veterinarian, but other medical
problems (e.g., skin disease/allergy, ostheoarthrosis) may have
only been based upon owner’s perception.
CONCLUSION
Dog owners with smaller dogs, older dogs, and certain breeds
known to be predisposed to periodontal disease, assessed their
dog’s dental health as worse than their counterparts, which is in
agreement with previously reported higher prevalence of dental
disease in these groups. This indicates that dog owners are able to
perform relative assessment of their dog’s dental health status.
The known high prevalence of dental disease, together with
the low reported frequency of professional dental cleaning
under anesthesia, highlights the need for routine professional
assessment of periodontal health and education of dog owners
on the importance of dental care. Dog owners’ difficulties in
inspecting their dog’s teeth underline the need for education
of dog owners and training of dogs to accept dental home
care procedures.
DATA AVAILABILITY STATEMENT
The data is available from the authors upon reasonable
request. The data are not publicly available due to them
containing information that could compromise research
participant privacy.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by the Regional Ethical Review Board in Uppsala (Dnr
2017/035). Written informed consent for participation was not
required for this study in accordance with the national legislation
and the institutional requirements.
AUTHOR CONTRIBUTIONS
KE writing: original draft and study design. CB statistical analysis,
writing: review and editing. JH, RH, OH, and PG: writing: review
and editing. AP conceptualization, study design, writing: review
and editing. All authors read and approved the final manuscript.
FUNDING
The Greater Stockholm Veterinary Hospital Foundation (major
contributor) (Recipient AP) and The Swedish Association for the
Protection of Animals (minor contributor) (Recipient AP). No
grant numbers are available. URLs: http://stiftelsendjursjukhus.
se/ and http://www.djurskydd.org/. Publication fee: Stiftelsen
Till min mors minne, Amanda Personnes fond URL https://
www.stiftelsemedel.se/stiftelsen-fru-amanda-personnes-
donationsfond-till-min-mors-minne/. The funders had no role
in study design, data collection and analysis, decision to publish,
or preparation of the manuscript.
ACKNOWLEDGMENTS
The authors express their gratitude to all dog owner respondents,
who by answering the questionnaire contributed to a better
understanding of how dental health in our dogs can be improved.
Anicura Albano Animal Hospital is kindly acknowledged for
their collaborative role in this research project.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fvets.
2020.00298/full#supplementary-material
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which does not comply with these terms.
Frontiers in Veterinary Science | www.frontiersin.org 10 June 2020 | Volume 7 | Article 298
... In a large-scale quantitative Swedish survey on dental care in dogs, we have shown that only 4% of Swedish dog owners brushed their dogs' teeth daily (22,24). So far, to the authors' knowledge, no other studies have attended to owners' beliefs and attitudes to dental care for dogs from a larger perspective. ...
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