ttp://www.bsava.

com REVIEW

A review of the frequency and impact of

periodontal disease in dogs
C. Wallis1,* and L. J. Holcombe*

WALTHAM Petcare Science Institute, Leicestershire, LE14, 4RT, UK

Corresponding author email: corrin.wallis@effem.com
1

Periodontal disease is a frequent problem seen in veterinary practices. Primary-care veterinary prac-
tices, where diagnosis of periodontal disease is predominantly based on visual oral assessment of
conscious dogs, report an average prevalence of 9.3 to 18.2% within the dog population. Detailed
examinations of anaesthetised dogs report much higher prevalence of between 44 and 100%. The
prevalence and severity of periodontitis varies between sizes of dogs, breeds and individuals. The lack
of robust evaluation of these variances opens the opportunity for a review of the topic. A literature
search was therefore undertaken to determine the frequency and extent (severity and oral location) of
periodontal disease in the dog population. Both clinical and retrospective data based surveys of
veterinary records, show there is an increased likelihood of developing periodontitis as age increases
and with bodyweight decreases. The maxillary and mandibular incisors, fourth premolars and first
molars are likely to develop the disease first although in some breeds the canines may also be
involved. Poor oral care is a significant risk factor for the development of periodontal disease although
diet, behaviour, environment and genetics are also likely to play a role. The information provided in this
review can be used by veterinarians to improve the effectiveness of their diagnosis, treatments and
interventions by focussing their efforts on the sizes, breeds and individuals most at risk. Given the
potential link between periodontal disease and systemic health, veterinarians have the opportunity to
positively impact the quality of life of a large number of dogs and therefore their owners.

Journal of Small Animal Practice (2020) 61, 529–540

DOI: 10.1111/jsap.13218
Accepted: 27 July 2020

INTRODUCTION
Periodontal disease is one of the most common diseases seen in
small animal practices (Lund et al. 1999, Robinson et al. 2016).
Given the global dog population extends into the millions, this
represents a huge problem. The diagnosis of periodontal disease
tends to occur late in the disease process (Niemiec 2008). With
this in mind, it is critical that veterinarians have the opportunity
to adequately diagnose and treat the disease at an earlier stage and
use the information to support preventative strategies. However,
information concerning the frequency and extent of periodontal
disease in different sizes and breeds of dog is incomplete. This
review summarises the scientific literature on the frequency and
extent of periodontal disease in the canine population to evaluate
the following criteria (1) the size and breed of dogs most at risk
of developing the disease, (2) the areas of the mouth most likely
to be affected and (3) potential risk factors. The purpose of this
review is to provide general practitioners information on diagnos-
tic efforts, prevention and treatment strategies relating to early
diagnosis of periodontal disease. As such, a search of PubMed
was undertaken using the term “(periodontitis OR ‘periodon-
tal disease’ OR gingivitis) AND (dog OR dogs OR beagle OR
beagles) AND (epidemiology OR prevalence OR incidence OR
frequency OR extent OR cross-sectional OR longitudinal OR
clinical)”. All articles were considered irrespective of cohort sizes
and methodologies. Their limitations are discussed within the
review. Only publications where periodontal disease had been
experimentally induced were excluded.

Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association 529

C. Wallis and L. J. Holcombe
PERIODONTAL DISEASE
Periodontal disease is an inflammatory condition that affects the
periodontium, the specialised tissues that surround and support
the tooth. The periodontium is comprised of the gingiva, cemen-
tum, periodontal ligament and alveolar bone. Periodontal disease
is initiated by the build-up of plaque on the tooth surface (Saxe
et al. 1967, Van Dyke 2009, Niemiec 2012). Plaque formation
occurs in three stages, initially salivary glycoproteins adhere to
the tooth surface to form the pellicle, this is followed by initial
bacterial adhesion and finally plaque maturation (Niemiec 2012,
Lobprise & Dodd 2019). Plaque can become mineralised to form
calculus (tartar) which does not directly initiate the disease but
does provide a porous surface to which new plaque can adhere
(Schroeder 1965, Legeros & Shannon 1979, Harvey 2005, Nie-
miec 2012, Gorrel 2013, Lobprise & Dodd 2019). It is gener-
ally accepted that the inflammation and resulting tissue damage
is due to an improperly regulated immune response to bacterial
infection rather than damage solely from bacterial pathogens
themselves (Van Dyke and Sheilesh 2005).
Periodontal disease is separated into two conditions; gingivi-
tis and periodontitis (Harvey 2005, Niemiec 2012). Gingivitis
is a reversible condition in which the gingiva becomes red and
inflamed. In periodontitis, the tissues that support the tooth
become inflamed, ultimately resulting in attachment loss due
to the destruction of the periodontal ligament, cementum and
alveolar bone. Periodontitis is irreversible but often manageable.
Different forms of human periodontitis have been described
by The American Academy of Periodontology (The Ameri-
can Academy of Periodontology 2015). Chronic periodontitis,
which often begins in adolescence but progresses slowly and
is not usually of clinical relevance until adulthood. Aggressive
periodontitis, which progresses more rapidly and tends to affect
pre-pubertal juveniles. Currently, it is not known if different
forms of canine periodontitis exist. Given that there are differ-
ent manifestations of periodontitis, and that gingivitis does not
always progress to periodontitis, it is believed that there are fac-
tors, other than dental plaque, that influence the host’s response
to the infection (Harvey 2005). Similarly to humans, these
factors may include those that are modifiable such as behav-
ioural or environmental (e.g. stress, nutrition, oral care, chew-
ing habits) or those which are intrinsic to the individual and
not easily changed (e.g. host response, genetic factors, ageing)
(Harvey 1998, Van Dyke and Sheilesh 2005, Van Dyke 2009,
Gorrel 2013, Niemiec 2012).
Early stage periodontal disease is not associated with severe
pain or discomfort but as the disease progresses periodontal
abscesses and ulcers in the mucus membranes can develop which
can be extremely painful (Niemiec 2008, Gorrel 2013). Addi-
tionally the continuing loss of attachment and associated bone
loss causes the tooth to become mobile and eventually lost (Har-
vey 2005, Niemiec 2012, Gorrel 2013). In some breeds, par-
ticularly smaller breeds such as Yorkshire terriers, alveolar bone
loss can result in pathological fracture of the mandible (Har-
vey 2005). Certain physical and behavioural changes are sug-
gestive of dental pain such as weight loss, abnormal aggressive
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behaviour or distress, abnormal eating behaviours, bleeding gin-
giva, shaking of the head, rubbing the face or digging the ground
(Niemiec 2012, Gorrel 2013). However, the main complaint of
the owner is usually halitosis (Gorrel 2013). The prevalence and
severity of periodontitis has been associated with pathological
changes in the kidney, myocardium and liver of dogs (Debowes
et al. 1996, Pavlica et al. 2008). There is also some evidence of
an increased likelihood of being diagnosed with endocarditis,
cardiomyopathy, hepatopathy, hepatitis and chronic renal failure
(Glickman et al. 2009, Pereira Dos Santos et al. 2019).
DIAGNOSIS OF PERIODONTAL DISEASE
A number of book chapters (Niemiec 2012, Gorrel 2013, Lob-
prise & Dodd 2019), scientific articles (Kortegaard et al. 2008)
and online veterinary education articles (WikiVet, https://
en.wikivet.net/Small_Animal_Dentistry) are available outlining
the criteria used to diagnose periodontal disease. It is therefore
not the intention of this review to detail how gingivitis and peri-
odontitis should be evaluated. However, a brief description of the
methodologies used is outlined below.
An initial assessment can be performed in conscious dogs to
visually assess the extent of gingivitis, plaque, calculus and any
obvious signs of clinical attachment loss such as gingival reces-
sion, root exposure and mobile or lost teeth. It should be noted
that the absence of teeth in the oral cavity is not necessarily the
consequence of periodontal disease. This could be due to the teeth
being impacted, congenitally missing or previously extracted for
reasons unrelated to periodontal disease such as fracture or tooth
resorption. Conscious examinations are limited in that not all
surfaces of the teeth can be visualised and it is not possible to
fully assess the amount of tissue loss around the tooth without
clinical probing and intra-oral radiographs. To determine the full
extent of periodontal disease a thorough examination of anaes-
thetised individuals is required. This enables issues below the
gingival margin to be evaluated through periodontal probing of
the periodontium to assess the full extent of gingivitis, pocket
depth and clinical attachment loss. Full mouth intra-oral dental
radiographs are also required to determine the type and extent of
alveolar bone loss.
The presence and severity of gingivitis is clinically diagnosed by
means of a combination of a visual inspection and examination of
the periodontium using a periodontal probe (Gorrel 2013). The
gingiva is visually inspected to determine the presence and degree
of gingival inflammation and the periodontal probe is used to
determine the presence or absence of bleeding when the gingiva
is probed. A gingivitis index is usually used to give a numerical
value to the degree of gingivitis present. For example if there is
no inflammation and no bleeding on probing when the tooth is
gently probed at several points it would be deemed healthy and
given a score of zero. Alternatively, if the gum was inflamed and
spontaneously bleeding it would be deemed to have severe gingi-
vitis and might be given a score of four (Gorrel 2013). Gingivitis
indices are subjective in that they rely on human interpretation
of the extent of inflammation and bleeding.

Review of canine periodontal disease
The presence and severity of periodontitis is determined
based on the extent of destruction of the periodontium and
can be assessed by measuring clinical attachment loss (also
known as periodontal attachment loss), periodontal pocket
depth, gingival recession and furcation exposure. The peri-
odontal pocket depth is measured by inserting a graduated
probe into the gingival sulcus and recording the distance from
the free gingival margin to the bottom of the gingival sulcus or
periodontal pocket (Gorrel 2013). Sometimes this can result in
an overestimation of the amount of clinical attachment loss if
the gingival margin is above the cemento-enamel junction due
to gingival inflammation or hyperplasia (Lobprise 2012, Gor-
rel 2013). Clinical attachment loss can also be determined by
summing the depth of the periodontal pocket and the extent
of gingival recession (distance from cemento-enamel junc-
tion to the gingival margin). Alternatively it can be measured
directly by measuring the distance from the cemento-enamel
junction to the bottom of the gingival sulcus or periodontal
pocket. Furcation exposure is where the alveolar bone has been
destroyed between the roots of a multi-rooted tooth. It is mea-
sured using a periodontal probe and graded based on how far
the probe passes horizontally between the tooth roots. Intra-
oral dental radiographs should be used in conjunction with
a clinical examination of the periodontium to determine the
type and extent of alveolar bone destruction (Gorrel 2013).
Changes associated with periodontitis include alveolar bone
loss, decreased alveolar bone density and widening of the
periodontal ligament space. The degree of severity of peri-
odontal disease, relating to a single tooth, has been defined
by the American Veterinary Dental College: Clinically nor-
mal (PD0); gingivitis (Stage 1, PD1), early periodontitis, less
than 25% attachment loss (Stage 2, PD2); moderate periodon-
titis, 25-50% attachment loss (Stage 3, PD3) and advanced
periodontitis, more than 50% attachment loss (stage 4, PD4)
(Wolf et al. 2005).
It should be noted that the depth of the gingival sulcus in dogs
with clinically healthy gingiva is between one and three millime-
tres and varies depending on the size of the dog (Gorrel 2013).
The extent of clinical attachment loss can vary between regions
of the mouth and even between neighbouring teeth emphasis-
ing the need to assess multiple aspects (e.g. mesial, distal, buc-
cal and palatal/lingual) of every tooth within the mouth. Loss
of attachment is not necessarily indicative of active periodonti-
tis, particularly if there is no gingival inflammation, as disease
progression is not always continuous and can be episodic in
occurrence (Harvey 2005, Gorrel 2013). Furthermore, gingivitis
severity is not always predictive of clinical attachment loss (Har-
vey 2005, Kortegaard et al. 2008, Case et al. 2010, Albuquerque
et al. 2012, Marshall et al. 2014).
PREVALENCE OF CANINE PERIODONTAL
DISEASE
A number of studies have been undertaken to determine the
frequency and extent of periodontal disease in dogs. The earli-
Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
17485827, 2020, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13218 by Cochrane Mexico, Wiley Online Library on [21/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
est epidemiological studies involved relatively small numbers
of beagle dogs that had been bred in research facilities. These
studies reported a high incidence of periodontal disease and
showed differences in the frequency and severity of the disease
even though dogs had similar housing conditions (Rosenberg
& Rehfeld 1967, Page & Schroeder 1981). More recently,
both cross-sectional and longitudinal studies in a number
of breeds from a variety of geographical locations have been
reported. Studies of dogs visiting primary-care veterinary prac-
tices have focussed on diagnosis of periodontal disease pre-
dominantly by visual oral assessment of conscious dogs. Other
studies have performed more detailed analyses in anaesthetised
dogs or have undertaken a retrospective analysis of skulls from
deceased animals.
It should be borne in mind that these investigations have
used a variety of methodologies making it difficult to com-
pare between studies. Study populations differ in terms of
breeds and sizes of dogs included, their geographical loca-
tion and their housing conditions (e.g. client-owned, shelter
and research facilities). Variations in sample size are consid-
erable and some studies may not have sufficient statistical
power to accurately determine the true prevalence of disease.
The age groups of the dogs included in the studies, and the
data collection periods and duration, differ which will affect
estimates of the frequency and extent of disease. Due to a
lack of standardised protocols there is no consistency in the
criteria used to diagnose and score gingivitis and periodon-
titis. Some studies examine every aspect of every tooth in
the mouth whereas others analyse subsets of teeth and sites.
Therefore, these methodological differences need to be con-
sidered when interpreting the scientific literature on the
prevalence, severity and extent of disease (Beck & Loe 1993,
Susin et al. 2005).
BEAGLE STUDIES
Beagles are a common breed of dog used within research studies
and hence there are a number of studies described within the
scientific literature. Histological and morphological analysis of
40 adult beagle dogs observed signs of periodontal disease in all
dogs (Hull et al. 1974). Despite the fact dogs were maintained
under identical conditions and were fed the same diets through-
out their lives, at a given age, the extent and severity of alveolar
bone loss varied considerably. Generally, young dogs showed
signs of gingivitis whereas older dogs showed evidence of bone
loss.
An assessment of the prevalence and severity of gingivitis and
periodontitis in a closed colony of 74 adult beagles reported
that the severity of attachment loss increased at 6 to 7 years of
age (Sorenson et al. 1980). A full-mouth site-specific examina-
tion of 98 research beagles identified clinical attachment ≥1 mm
in 20% of dogs aged 1 year and 84% in dogs aged more than
3 years (Kortegaard et al. 2008). All dogs exhibited bleeding on
probing irrespective of age. The later stages of periodontitis,
pocket depth of ≥4 mm was observed in 44% of dogs aged 2
531

C. Wallis and L. J. Holcombe
and 81% of dogs greater than 3 years of age. This study also
highlighted that the majority of the disease burden was carried
by a few individuals.
PRIMARY-CARE STUDIES
Electronic patient records from primary-care veterinary prac-
tices have been proposed as a reliable means of obtaining
prevalence data for a variety of conditions in the overall dog
population (Mcgreevy 2007, Bateson 2010). Data from veteri-
nary practices can be combined, providing the data has been
recorded in a consistent manner, resulting in large datasets that
are representative of the overall dog population. However, the
majority of these records are based on conscious visual exami-
nations of the dog’s mouth which, as previously mentioned,
is likely to result in under reporting the prevalence of peri-
odontal disease. In addition, primary-care veterinary practice
data were not intended for research purposes and are there-
fore potentially susceptible to known and unknown biases. For
example, it cannot be assumed that every time a dog visits the
veterinary practice it has an oral examination with the findings
accurately entered into the database. Despite these limitations,
and because of the large number of pet medical records anal-
ysed, comparisons across breeds are still likely to be valuable
assuming data have been collected consistently across all breeds
of dog.
Detailed analysis of 3884 electronic patient records of
dogs visiting primary veterinary practices across central and
south-eastern England reported the overall prevalence of
periodontal disease as 9.3% (O’Neill et al. 2014). A higher
overall prevalence of 18.2% was reported for dogs visit-
ing primary veterinary practices in the USA (Wallis et al,
unpublished data). This retrospective analysis of over 3
million medical records indicated that the breeds most fre-
quently diagnosed with periodontal disease tended to be in
the extra-small (<6.5 kg), small (6.5-9 kg) and medium-
small (9-15 kg) breed size categories. Generally the medium-
large (15-30 kg), large (30-40 kg) and giant (>40 kg) breed
size categories had a lower prevalence of periodontal disease
with the exception of greyhound and basset hound (Fig 1).
The highest prevalence of periodontal disease was reported
in Yorkshire terrier, followed by cocker spaniel, Jack Rus-
sell terrier, border collie, German shepherd dog, Labra-
dor retriever and finally Staffordshire bull terrier (O’Neill
et al. 2014). Analysis of data from the VetCompass™ Pro-
gramme, which collates de-identified clinical data from pri-
mary-care veterinary practices in the UK for epidemiological
research, indicated that periodontal disease was one of the
most prevalent disease of greyhounds (39% of dogs affected)
and miniature schnauzers (17.4%) (O’Neill et al. 2019a,b).
These studies show that there is substantial variation in the
prevalence of periodontal disease across breeds and provide
insights into the sizes and breeds of dogs that are most at
risk.
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CROSS-SECTIONAL STUDIES
A cross-sectional survey of 62 mongrel dogs found that dogs
less than 3 years of age had severe gingivitis whereas those aged
9 to 11 years had periodontitis (Gad 1968). Assessment of the
degree of gingival inflammation in 251 mongrel dogs from Japan
showed that 29.2% of stray dogs aged between 0.5 and 1.5 years
had gingivitis which increased to 78.6% in dogs aged five and
above (Isogai et al. 1989). For every age group, the pet dogs had
a lower prevalence of gingivitis than the stray dogs.
Macroscopic and radiographic analysis of skulls from 162 mon-
grel and purebred dogs observed periodontitis in 63.6% of dogs
which increased to over 80% in dogs over 6 years of age (Hamp
et al. 1984). The study found that the prevalence of periodontitis
varied markedly among and within different breeds. Periodonti-
tis was more frequently observed, and was more severe, in small
dogs compared to larger dogs. Poodles had a higher frequency
and more severe forms of periodontitis than German shepherd
dogs. Dachshunds (small breed) and boxers (large breed) had
slightly fewer teeth affected by periodontitis than poodles but
more than most other breeds in the study. This study found that
the numbers of teeth affected varied markedly between dogs of
the same breed. A similar prevalence of periodontitis (60%) was
reported in a retrospective study undertaken at a Czech urban
veterinary hospital (Kyllar & Witter 2005). A slightly lower over-
all prevalence of periodontitis (56.9%) was reported in a survey
of 1350 dogs visiting veterinary hospitals in the USA and Canada
(Harvey et al. 1994). This study also reported that the gingival
index and attachment loss decreased significantly with increasing
bodyweight. A retrospective radiological study of 235 purebred
dogs and 24 mongrels reported an even lower prevalence of peri-
odontitis at 44.4% (Butković et al. 2001). Periodontitis was not
observed in dogs less than 2 years of age but by 2-8 years of age
76.3% of dogs had periodontitis and this increased to 100% of
dogs in the 8 to 15 year age group. The highest level of peri-
odontitis was observed in medium-size breeds (39.5%), followed
by large breeds (26.3%), small breeds (20.0%) and mongrels
(14.0%). In terms of breed differences, this study reported the
highest levels of periodontitis in medium-sized poodle (20%)
followed by German shepherd dog (11.5%), toy poodle (10%),
boxer (9%), German hunting dog (8%) and Chihuahua (2%). A
study of 123 poodles reported that 90% of dogs under the age
of 4, and 100% of dogs over the age of 4, had at least one tooth
affected by periodontitis (Hoffman & Gaengler 1996).
In summary, the prevalence of periodontitis varies consider-
ably between studies. Assessment of dogs visiting primary-care
veterinary practices, predominantly based on visual examination
of conscious dogs, report levels between 9.3 and 18.2%. Clini-
cal assessment of anaesthetised animals or necroscopy samples
report higher levels between 44 and 100%. There is high vari-
ability in the prevalence and severity of periodontitis between
sizes and breeds of dog and individuals within a breed (Hoff-
man & Gaengler 1996). In many of the studies, even young
dogs were exhibiting signs of periodontal disease (Hoffman &
Gaengler 1996). Although the true prevalence of periodonti-
 40
Cavalier King
g Charles spaniel
Miniatur
a e poodle
Shetland sheepdog
g
Bichon Frise
Ameerican Eskimo Greyhound
T y poodle
To d
S
Standar d sch
hnau
a zerr
Dachshund
a s
R t ter
Ra t rier Breed Size Extra-Small Small Medium-Small
Papillon
a o
West Highlan
a d Whit
h e ter
t rier Medium-Large Large Giant
30
Cai
a rn ter
t rier
e
American coc
o ker spaniel
Beagle

Fox terrier
er Basset Hound
d
Maltese
es

American Staffordshirre terrier

20 Bruss
ssels Grififffon L rado
Lab adorr ret
retrriever
Stttandar
n d poodle Bernese
e Mountain Dog
Y rkshire ter
Yo e rierr Golden rettriever
Welsh Corgi
gi
Chihuahua Border Collie Dobermann
o Bloodhound

Periodontal Disease (%)

Miniature Pinscher
ns Australian shepherd
e
Pug Rhode n Ridgeback
Rhodesia a
Boston terrier Rottweiler
Pomeranian
n Pekingese
ess
Sain
a t Bernard
Australia
a n Cattle Dog
Miniature
e schnauzer
Shih-tzu Sibe
b ria
an Husky Akita
10 Lhasa Apso
Lhasa s
Jack Russel
e l terrier Great Dane
Weimaraner
Englis
i h Bulldog Great Pyrenees
y
Boxer Newfoundland
a
Alaskan Mala
M mute
Bullmastiff
Pit bull German shepherd
p dog
g
Review of canine periodontal disease

Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
American Bulldog
French Bulldog Pres
e a Canario

Cane Corso
o
0
10 20 30 40 50
Breed Average Size (Kg)

FIG 1. Graphical representation of the 5-year period prevalence of periodontal disease in the 10 breeds of dog in each size category (extra-small <6.5 kg, small 6.5-9 kg, medium-small 9-15 kg,
medium-large 15-30 kg, large 30-40 kg and giant >40 kg) that most frequently visited Banfield® Pet hospitals (Wallis et al., unpublished data). The colour of the dots depicts the breed size category
and the size the prevalence of periodontal disease (low prevalence small through to high prevalence large). Percentages on the X-axis are the prevalence of periodontal disease for each of the breeds
of dog

533
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C. Wallis and L. J. Holcombe
tis is not conclusive, the majority of studies agree that smaller
breed dogs are more prone to periodontal disease than larger
breed (Hamp et al. 1984, Harvey et al. 1994, Harvey 1998).
Table 1 provides a summary of these cross-sectional studies and
highlights the population and methodological differences across
studies.
LONGITUDINAL STUDIES
To the authors knowledge only three longitudinal studies have
been performed with the sole purpose of investigating the devel-
opment of gingivitis and periodontitis. These types of study not
only enable the percentage of a population affected by gingivitis
and periodontitis at a given time (prevalence) to be determined
but also enable the number of new cases (dogs, teeth or aspects)
in the population over a given period of time (incidence) to be
established. Furthermore, changes in the rate of disease acquisi-
tion can be ascertained. The main disadvantage of these stud-
ies is that they represent a relatively small number of dogs of
a single breed and although the measurement of gingivitis and
periodontitis was consistent across studies, they differed in
terms of study design. In these studies, the level of disease was
determined around the whole gingival margin of every tooth in
the mouth.
A longitudinal study of 52 miniature schnauzers, aged 1.3 to
6.9 years, where the extent of periodontal disease was assessed
every 6 weeks for up to 60 weeks found that all dogs had gin-
givitis at the start of the study despite the fact dogs received
daily tooth brushing up to the start of the study (Marshall
et al. 2014). The majority of aspects (mesial, distal, buccal
and palatal/lingual) (66.3%) were deemed very mild gingivi-
tis. Over the course of the study, 98% of the dogs developed
periodontitis and the number of teeth within a dog that pro-
gressed to periodontitis ranged from 0 to 21. Assessment of the
periodontal health status of 53 Labrador retrievers, aged 1.1 to
5.9 years, also found that all dogs had gingivitis at the initial
assessment (Wallis et al. 2018). The severity of gingivitis was
similar to that of miniature schnauzers in that the majority of
aspects (mesial, distal, buccal and palatal/lingual) (64.2%) were
deemed very mild gingivitis. Six monthly assessments for up
to 2 years established that 56.6% of the dogs developed peri-
odontitis and animals as young as 1.9 years were affected. The
frequency of periodontitis was much higher in Yorkshire terriers
where 98% of dogs (n = 49) had the early signs of periodon-
titis at 37 weeks of age, depicted by periodontal pockets and
alveolar bone loss (Wallis et al. 2019). At 78 weeks, 36 of the
dogs (72%) had the periodontal health status re-assessed which
showed that the odds of periodontitis were nearly three times
higher compared to 37 weeks of age. This study suggested there
may be a litter effect as the average percentage of periodontitis
teeth in a mouth was significantly different across litters vary-
ing from 15.8 to 55.3%. Table 2 provides a comparison of the
frequency and extent of disease across the three longitudinal
studies.
534 Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
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REGIONS OF THE MOUTH AFFECTED
Periodontal disease is a site-specific disease in that one or more
aspects of the gingiva and teeth may be affected. Several stud-
ies report that the disease more often affects the maxillary teeth
compared to the mandibular teeth (Hamp et al. 1984, Kyllar &
Witter 2005, Kortegaard et al. 2008, Wallis et al. 2019). In con-
trast, others have shown that similar teeth are affected on both
jaws but the pattern is less pronounced on the maxilla (Marshall
et al. 2014). Most studies agree that the premolars and molars,
in particular fourth premolar and the first molar, are the teeth
that are most frequently affected (Lindhe et al. 1975, Soren-
son et al. 1980, Hamp et al. 1984, Isogai et al. 1989, Harvey
et al. 1994, Hoffman & Gaengler 1996, Kortegaard et al. 2008).
Other studies however have reported that the canines have
the highest frequency and severity of gingivitis and periodon-
titis (Harvey et al. 1994, Hoffman & Gaengler 1996, Wallis
et al. 2019), whereas others have indicated that the incisors are
among those teeth at highest risk of developing the disease (Mar-
shall et al. 2014, Wallis et al. 2018). The incisors, first premolar
and first molar teeth were also most often reported as missing,
presumably as a result of periodontal disease (Isogai et al. 1989,
Harvey et al. 1994, Hoffman & Gaengler 1996, Kyllar & Wit-
ter 2005). As mentioned previously these differences are most
likely due to population and methodological differences. How-
ever, comparison of studies where the teeth, aspects (mesial, dis-
tal, buccal and palatal/lingual) and scoring criteria are similar,
suggests that breed differences in the teeth affected may exist.
Figure 2 shows a schematic of dog jaws highlighting differences
in the teeth affected across three breeds of dog: Labrador retriever,
miniature schnauzer and Yorkshire terrier (Marshall et al. 2014,
Wallis et al. 2018, 2019).
Studies have shown that the palatal/lingual aspect is most
likely to bleed when probed and, in particular, this aspect of
the incisors is most likely to develop the disease first (Marshall
et al. 2014, Wallis et al. 2018). In terms of premolars and molars
all aspects have been reported to be at risk of developing gin-
givitis and periodontitis (Sorenson et al. 1980, Kyllar & Wit-
ter 2005, Marshall et al. 2014).
These differences across studies highlight the importance of
probing multiple aspects of every tooth in the mouth. It also
underscores the need for more breed-specific studies to under-
stand differences in disease manifestation between the various
breeds of dog. It should be understood that the clinical relevance
for each of the teeth will differ depending on the length of the
root and the number of aspects affected. For example a 4-mm
periodontal pocket on every aspect of an incisor may represent
50% attachment loss but on a canine the level of attachment loss
would be much less.
RISK FACTORS
A risk factor is defined as an occurrence or characteristic that has
been associated with the increased susceptibility to a disease. It is
 Table 1. Summary of cross-sectional studies which investigated the prevalence of gingivitis and periodontitis in dogs
Gad 1968 Isogai et al. 1989 Hamp et al. 1984 Kyllar & Witter 2005 Harvey et al. 1994 Burt 2001 Hoffman & Gaengler 1996
Number of 62 251 162 408 1350 259 123
dogs
Breed Mongrel dogs Mongrel dogs (108 pet dogs 150 purebred dogs (50 Grouped according to 160 pure breeds: 235 purebred (23 Poodles divided into three groups:
and 143 strays) different breeds) and size small (<10 kg), >50 records: breeds) and 24 normal home diet, carbohydrate-
12 mongrels medium-sized (10- beagle, cocker mongrels Breeds rich non-abrasive diet and
Breeds ≥10 individuals; 30 kg) and large spaniel, German ≥10 individuals; toy protein-rich abrasive diet
toy and miniature (>30 kg) shepherd dog, poodle, Chihuahua,
poodles, German standard poodle poodle, German
shepherd dog, and mixed breeds shepherd dog,
Dachshunds, boxers German hunting
terrier, boxer
Age 3 months to <0.5 to ≥5 years 7 months to 14 years 1 to 13 years <1 year (with 7 months to 15 years 2 years to >12 years
12 years permanent teeth)
to >14 years
Population Veterinary Stray and pet dogs, Japan Necroscopy samples, Czech urban Veterinary practices, Veterinary University, Veterinary practice, Germany
practice, Sweden veterinary hospital USA and Canada Croatia
Copenhagen (2003-2004)
Study period Undefined February to December 1985 Undefined 2003-2004 Undefined 4-year period Undefined
Teeth Undefined Full-mouth Incisors excluded Incisor, premolar and Subsets of teeth Full-mouth Full mouth
assessed molar region on
labial/buccal and
lingual/palatal side
Diagnosis Periodontal Gingival Index system by Bone loss post mortem Plaque accumulation Missing teeth Bone loss dental Pocket depth (gingival margin to
criteria Index Löe and Silness (27) (Radiographs – total and gingival recorded radiographs bottom pocket), Attachment
(Russell with some modifications amount of supporting inflammation using bilaterally, mobility loss (AL; distance from CEJ to
1956) and were classified into alveolar bone lost; modified Silness and furcation bottom of pocket), Bleeding on
4 ranks (0, 1, 2, 3), only slight periodontitis and Loe plaque exposure recorded probing All above were on six
buccal region assessed. <1/3 total amount of index unilaterally. sites of each tooth. Missing
Radiographs of all supporting alveolar Calculus teeth classified as 1) sound (no
maxillary and mandible bone and advanced deposition, gingival bleeding/periodontal pockets
teeth regions obtained for periodontitis >1/3) index, furcation or AL), 2) gingivitis (bleeding on
Review of canine periodontal disease

Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
some animals to detect involvement and probing w/o periodontitis), 3)
alveolar bone loss in loss of attachment periodontitis (PD or AL; slight
accordance with method of (distance in mm PD 3 to 5 mm or AL 2 to 4 mm,
Lindhe et al (1975) from CEJ to bottom moderate to severe PD > 5.5
of pocket) on to 8 mm or AL > 7 mm, severe
selected set of PD > 8 mm or AL > 7 mm) Plaque
teeth and calculus accumulation
Probing Not measured Undefined Not measured Early periodontal Not measured Periodontitis divided into three
depths disease probing categories: P1 slight: probing
depth <2.5 mm, depth 3-5 mm (or attachment
moderate loss 2 to 4 mm), P2 moderate
periodontal disease to severe: 5.5 to 8 mm (4.5
probing depth to 7 mm), P3 severe >8 mm
<5 mm, severe (>7 mm)
periodontal disease
probing depth
>5 mm
Percentage Undefined Gingivitis 0 to 78.6% 63.6 to 80% 60.0% 56.9% 44.40% 90 to 100%
periodontitis

535
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 17485827, 2020, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13218 by Cochrane Mexico, Wiley Online Library on [21/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C. Wallis and L. J. Holcombe

Table 2. Comparison of the frequency and extent of periodontitis in Labrador retrievers, miniature schnauzers and
Yorkshire terriers (Marshall et al. 2014, Wallis et al. 2018, 2019). A requirement of the WALTHAM Animal Welfare and
Ethical Review Body was that dogs were removed from trial when 12 or more teeth developed periodontitis
Labrador retriever Miniature schnauzer Yorkshire terrier

Number of dogs 53 52 50
Age range at start of study 1-6 years 1-7 years 0.7 years
Duration of study 24 months 12 months 10 months
Frequency of oral assessments 6 monthly 6 weekly 8 weekly
% dogs with periodontitis 57 98 98
% of teeth assessed with 6 28 30.5
periodontitis
% dogs removed from trial 0 67 100*
Youngest dog with periodontitis 1.9 years 1.3 years 0.7 years
Teeth most affected Incisors, fourth premolar, first molar Incisors, fourth premolar, first molar Incisors, canines
Aspect most affected Palatal/lingual Palatal/lingual All
100% of Yorkshire terriers* removed from trial by 45 weeks of age

merely an association and does not necessarily mean that it causes
the disease (Burt 2001). The studies described suggest that differ-
ent breeds of dog, and individuals within a breed, may respond
differently to the presence of plaque on the tooth surface. This
suggests that the ability to resist a given gingival bacterial load
varies among individuals depending on other factors.
Poor oral care is the most significant risk factor for the
development of periodontal disease. A number of studies have
shown that the build-up of dental plaque on dogs’ teeth is
often associated with the severity of gingivitis and periodontitis
(Saxe et al. 1967, Gad 1968, Lindhe et al. 1975, Page & Schro-
eder 1981, Isogai et al. 1989, Harvey 1998). Furthermore, dis-
tinctive bacterial communities have been associated with healthy
and diseased gingiva suggesting that the types of bacteria pres-
ent may have a role to play in the development of the disease
(Davies et al. 1997, Riggio et al. 2011, Davis et al. 2013, Wallis
et al. 2015).
A significant genetic influence on periodontal disease has been
suggested in human studies (Nares 2003, Yoshie et al. 2007).
Studies of identical twins suggest that 50% of susceptibil-
ity to periodontal disease is due to host factors (Michalow-
icz et al. 2000). It has been suggested that there may also be a
genetic predisposition to periodontal disease in dogs (Rosenberg
& Rehfeld 1967, Hamp 1975, Hennet & Harvey 1992, Wallis
et al. 2019). Numerous studies have also shown that periodontal
disease significantly increases in frequency and severity with age
(Rosenberg & Rehfeld 1967, Gad 1968, Hull et al. 1974, Soren-
son et al. 1980, Hamp et al. 1984, Isogai et al. 1989, Harvey
et al. 1994, Hoffman & Gaengler 1996, Butković et al. 2001,
Kyllar & Witter 2005, Kortegaard et al. 2008, Marshall
et al. 2014, Wallis et al. 2018, 2019). It has been hypothesised
that this could be due to a decline in immune function with age
(Greeley et al. 1996, Kearns et al. 1999, Blount et al. 2005, Mar-
shall et al. 2014).
Differences in oral morphology may also explain why some
breeds and individuals are more predisposed to periodontal
disease. Dogs of smaller bodyweight have proportionally larger
teeth than larger dogs. Small breed dogs are more likely to have
a malocclusion, potentially leading to overcrowding of the teeth
(Harvey 1998, Gioso et al. 2001). This general overcrowding
results in more crevices in which dental plaque can accumulate
(Niemiec 2012). Studies have also shown that the gingiva and
alveolar bone is significantly thinner in toy breed dogs compared
with small and medium-sized breed dogs and that thinner gin-
giva correlates with an increased incidence of periodontal dis-
ease (Kyllar et al. 2013). Furthermore, the disease process may
be exacerbated due to differences in jaw size with smaller dogs
having less bone supporting the teeth resulting in more severe
symptoms (Harvey 2005).
Nutritional factors have the potential to affect oral tissues and
therefore may play a role in the development of periodontal dis-
ease. A review article describing dietary influences on periodon-
tal health in dogs has been published previously (Logan 2006).
Briefly, however, positive correlations between calcium deficiency
and periodontal disease have been established from human stud-
ies and it has been suggested that calcium poor diets may enhance
the progression of periodontitis (Henrikson 1968). A more
recent study of dogs reported a statistically significant correlation

536 Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
 17485827, 2020, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13218 by Cochrane Mexico, Wiley Online Library on [21/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Review of canine periodontal disease

FIG 2. Schematic of a dog jaw depicting the extent of periodontitis within the mouth for three breeds of dog: (A) percentage of teeth that developed
periodontitis during a 2-year adult study of Labrador retrievers (Wallis et al. 2018); (B) percentage of teeth that developed periodontitis during
60-week study of adult miniature schnauzers (Marshall et al. 2014); (C and D) probability of each tooth developing periodontitis in Yorkshire terrier at
37 and 78 weeks of age, respectively (Wallis et al. 2019). The colours represent the average percentage of periodontitis on each tooth ranging from
blue (0%) to red (100%).

Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association 537

C. Wallis and L. J. Holcombe
between lower serum ionised calcium levels and more advanced
stages of periodontal disease (Thomas et al. 2015). The data is
potentially confounded in that older dogs had lower serum ion-
ised calcium levels. Also, as bodyweight decreased, the level of
periodontal disease increased. Some studies have suggested that
soft diets lead to a greater accumulation of dental plaque and
calculus which potentially increases the likelihood of developing
periodontal disease (Gawor et al. 2006). However, the evidence is
weak as other studies have found no correlations between dietary
consistency and disease incidence (Harvey et al. 1996, Hoffman
& Gaengler 1996, Harvey 1998).
It has been reported that people under psychological stress
are more likely to develop clinical attachment loss and loss of
alveolar bone (Van Dyke and Sheilesh 2005). The presence of
other diseases or decreased resistance to infection (e.g. metabolic
disease, nutritional disturbances and immunodeficiency) has also
been implicated, as well as other as yet undetermined factors
(Harvey 1998).
PREVENTION AND TREATMENT
The aim in prevention and treatment of periodontal disease is
to establish and maintain clinically healthy gingiva by prevent-
ing plaque build-up on the tooth surface and consequently
preventing inflammation (Lindhe et al. 1975, Harvey 1998,
Gorrel 2013). Once formed, calculus cannot be removed except
by performing a professional dental cleaning under anaesthesia.
Unfortunately, within minutes to hours of a thorough profes-
sional teeth cleaning, a layer of salivary glycoproteins begins to
form on the surface of the tooth which is subsequently colo-
nised by bacteria to form dental plaque (Ray & Eubanks 2009,
Holcombe et al. 2014). This means that the benefits of a pro-
fessional dental cleaning are lost within days of the procedure
and should be accompanied by a long-term prevention strategy
(Harvey 2005). The key to good oral health is through regular
and effective homecare combined with periodic health checks
and treatment by a veterinarian.
Tooth brushing is considered one of the most effective means
of removing plaque (Saxe et al. 1967, Lindhe et al. 1975, Gor-
rel & Rawlings 1996, Niemiec 2008). However, this is rarely
provided due to poor owner compliance, their lack of techni-
cal ability or the dog’s non-acceptance of the process (Lob-
prise 2006, Ray & Eubanks 2009, Gorrel 2013). However,
even with effective tooth brushing, plaque management on
the lingual and palatal surfaces of teeth or in grooves can be
difficult. There are a number of potentially useful adjuncts
to tooth brushing such as dental diets and chews, oral rinses
(e.g. chlorhexidine), water additives and gels (Harvey 2005,
Quest 2013). Appropriate chew toys may also help impede
plaque and calculus accumulation (Harvey et al. 1996). Given
the huge array of dental products available, the Veterinary Oral
Health Council (VOHC) was established in the USA to review
and recognise dental products that achieve their pre-set stan-
dards for the prevention of plaque and calculus accumulation.
Products are awarded the VOHC Seal of Acceptance providing
538 Journal of Small Animal Practice • Vol 61 • September 2020 • © 2020 British Small Animal Veterinary Association
17485827, 2020, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsap.13218 by Cochrane Mexico, Wiley Online Library on [21/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
trials have been conducted according to VOHC protocols and
the standard is achieved. This provides a means for veterinarians
and owners to select products which have been proven to be
efficacious for plaque and calculus prevention. The effectiveness
of homecare regimens should be monitored by a veterinarian
and in most cases will still require professional intervention. If
effective homecare is not achievable, or the dog already has late
stage disease, tooth extraction might be the best option for the
pet (Lobprise 2006).
DISCUSSION
Periodontal disease is a significant issue for the veterinary pro-
fession due to its high prevalence. The majority of dogs in the
population have gingivitis and the likelihood of developing peri-
odontitis increases with age. Periodontal disease is also inversely
related to bodyweight. There is a large variation in susceptibility
to periodontal disease among breeds, individuals and the extent
of the disease from tooth to tooth. The reported prevalence of
periodontitis in the dog population varies widely and dispari-
ties are likely due to population and methodological differences
between studies. Future studies are still needed to more precisely
determine the prevalence of periodontal disease in different
breeds of dog. Research is also needed to understand the role of
genetics in the disease process as well as determining if behav-
ioural and environmental contributions exist in the development
of disease.
This review of periodontal disease provides information that
can be used by veterinarians to improve the effectiveness of diag-
nosis, treatments and interventions by helping them focus their
efforts on the sizes, breeds and individuals most at risk. Ideally
as a minimum, veterinarians should perform a conscious exami-
nation of every dog each time they visit the veterinary practice
to determine their risk of periodontal disease. Veterinarians can
utilise the information in this review to aid conversations with
the owners about a pet’s risk to periodontal disease. This will
help to establish credibility and consequently enables the owner
to make informed decisions about treatment strategies. Veteri-
narians should stress to the owner the importance of an effective
homecare regimen for maintaining their pet’s oral health. Given
the prevalence of periodontitis and the potential link between
periodontal disease and systemic health, veterinarians have a
huge potential to positively impact the quality of life of dogs and
their owners.
Acknowledgments
The authors wish to acknowledge Ciaran O’Flynn and Ruth
Staunton for their significant contribution in creating the fig-
ures. This review was funded by Waltham Petcare Science Insti-
tute (Mars Petcare) the employer of Corrin Wallis and Lucy
Holcombe. CW and LH reviewed the literature and drafted and
revised the manuscript.
Conflict of Interest
No conflicts of interest have been declared.

Review of canine periodontal disease
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