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Chapter 1 Oral Examination and Charting

INDICATIONS

“Every mouth, every time”: a complete oral examination should be performed whenever possible to detect lesions as early as possible.

Make it a part of puppy and kitten exams to start a lifetime of oral care:Deciduous occlusion.Broken or damaged teeth.Proper eruption sequence.Brushing/home care instruction.

Continue with oral examinations at each visit, making oral care a cornerstone of a wellness program.

An alert oral exam can give a quick overview of oral conditions in most patients.

A complete oral examination can only be performed under general anesthesia and will include physical examination of the oral and dental structures, periodontal probing, transillumination, and intraoral radiography.

EQUIPMENT AND RESOURCES (see Chapter 9)

Alert Examination

Adequate but gentle restraint

Good lighting

Charts

Gloves

Complete Examination

General anesthetic components, including monitoring

Good lighting

Soft mouth blocks (gauze, spiral perm rollers): do not use spring‐loaded mouth gags, which can damage teeth or strain the temporomandibular joint unnecessarily, and can cause blindness in cats when they compress the maxillary artery

Magnification (usually needed): loupes

Periodontal probe/explorer

Mirror (Figure 1.1)

Transilluminator

Charts

Figure 1.1 A dental mirror allows you to examine the distal aspects of molars during therapy.

Figure 1.2 Before looking inside the mouth, examine the entire head for abnormalities, such as the generalized swelling of the face of this dog (oral mass).

PROCEDURE

Alert Examination

Use great caution with anxious or aggressive animals or those in pain; examination may have to be accomplished under sedation (carefully) or when the patient is anesthetized.

With the patient gently restrained on the table or floor, first observe the external structures of the head for any irregularities: symmetry, swelling (Figure 1.2), discoloration, discharge; note any malodor (halitosis).

Gently hold the muzzle closed with your nondominant hand, and lift up the lips to observe the buccal/labial surfaces of the teeth. Note and record:Accumulations of plaque and/or calculus (Figure 1.3).Missing teeth (circle on chart).Supernumerary teeth.Worn (AT for attrition), chipped, broken (FX for fractured) or discolored teeth.Gingival inflammation, overgrowth or recession.Red or bleeding gingiva: draining tract (parulis), purulent discharge.Gingival enlargement.Possible presence of tooth resorption (TR) – feline and canine.Position of teeth (occlusion).Incisors should be in “scissor bite” (Figure 1.4).Lower canine should be spaced equally between upper third incisor and upper canine.Premolars should interdigitate in a “pinking shear” configuration.Individual teeth in proper position.Oral soft tissues.Any fistula or defects.Note if any unusual masses are present; press up in the intermandibular space to lift tongue to view sublingual area (Figure 1.5).

If the patient is not in pain, and will allow it, briefly open the mouth:Assess palate.Look at tongue, and even raise the tongue pushing with your finger in the intermandibular space.Caudal mouth: assess inflammation in any possible stomatitis case.

With discolored teeth, occasionally a patient will allow you to transilluminate the tooth during the initial exam.

Figure 1.3 During the alert exam in anxious patients, caution may be needed to carefully lift the lips with gentle restraint (use a tongue depressor to preserve your fingers), so the extent of calculus and plaque can be estimated (significant accumulations in this patient).

Figure 1.4 This patient shows a variation from a correct “scissors” bite, with the left maxillary first incisor positioned behind the mandibular incisors (rostral crossbite).

Figure 1.5 With a cooperative patient, the tongue can be elevated by pushing up with a finger in the intermandibular space.

Complete Examination Under General Anesthesia

Reevaluate occlusion before intubation.

Initial identification of significant lesions to help treatment planning and inform owner of unexpected problems (“red flag check”).

Continue more extensive evaluation of above indices (Table 1.1):Plaque index.Calculus index (Figure 1.6).Gingival index.TABLE 1.1 Periodontal indices.Plaque index (PI) PI 0No observable plaquePI 1Plaque covers less than one‐third of buccal surfacePI 2Plaque covers between one‐ and two‐thirds of buccal surfacePI 3Plaque covers greater than two‐thirds of buccal tooth surfaceCalculus index (CI) CI 0No observable calculusCI 1Calculus covering less than one‐third of the buccal tooth surfaceCI 2Calculus covering between one‐ and two‐thirds of the buccal surface with minimal subgingival extensionCI 3Calculus covering greater than two‐thirds of the buccal surface and extending subgingivallyGingival index (GI) GI 0Normal healthy gingiva with sharp, noninflamed edgesGI 1Marginal gingivitis; minimal inflammation at the free margin; no bleeding on probingGI 2Moderate gingivitis; wider band of inflammation; bleeding on probingGI 3Advanced gingivitis; inflammation clinically reaching mucogingival junction; spontaneous bleeding sometimes presentFigure 1.6 A more accurate assessment of the extent of plaque and calculus accumulation can be determined under anesthesia. This patient shows moderate calculus accumulation (CI 2) and plaque accumulation (PI 2, covering the calculus).

Missing teeth: radiograph for embedded or unerupted teeth (see Chapter 14).

Supernumerary teeth: evaluate for potential interference, crowding (see Chapter 15).

Abnormal teeth: aberration in size, structure; evaluate for vitality (see Chapter 16).

Worn, chipped or fractured teeth; discolored teeth (see Chapters 24, 26 and 37).Evaluate surface and determine if canal exposed (use periodontal explorer) (Figure 1.7).Transilluminate to assess pulp vitality:Place the transillumination beam behind the tooth being observed, and examine the extent of light transmitted through the tooth.Vital teeth should transilluminate well, allowing light to pass through the tooth structure, even showing the pink of the pulp (Figure 1.8).Figure 1.7 Explorer used to detect pulpal exposure of this left mandibular canine (complicated crown fracture).Figure 1.8 Transillumination of this maxillary left second incisor shows good light transmission: the pulp is apparently vital.Nonvital teeth will not transilluminate well, appearing dark or dull, especially in the chamber portion (central), though the light will sometimes shine through the peripheral dentin to some degree (Figure 1.9). Note that the great majority of discolored teeth are nonvital and should be treated (Figure 1.10).Further evaluate with radiographs.Radiograph to evaluate periapical bone, canal size.

Mobile teeth: assess periodontal status and/or root fractures (Table 1.2).Figure 1.9 Transillumination of this maxillary right canine shows poor light transmission: the pulp is apparently nonvital and warrants further diagnostic evaluation (radiography).Figure 1.10 Assessing the open canal and apical bone loss on this radiograph confirms that the canine shown in Figure 1.9 is nonvital and requires therapy (root canal or extraction).TABLE 1.2 Tooth mobility (M) index.M0Physiologic mobility up to 0.2 mmM1The mobility is increased in any direction other than axial over a distance of more than 0.2 mm and up to 0.5 mmM2The mobility is increased in any direction other than axial over a distance of more than 0.5 mm and up to 1.0 mmM3The mobility is increased in any direction other than axial over a distance exceeding 1.0 mm or any axial movementTABLE 1.3 Common dental abbreviations.ALAttachment lossOMOral massATAttrition (wear)ONFOronasal fistulaCACariesPEPulp exposureCWDCrowdingPPPeriodontal pocketEDEnamel defectRDRetained (persistent) deciduousEPEpulisRERoot exposureFEFurcation exposureROTRotated toothFXFractureRPCRoot planing, closedGHGingival hyperplasiaRPORoot planing, openGV/GVPGingivectomy/plastyRTRRetained rootLPSLymphocytic plasmacytic (caudal) stomatitisTRTooth resorptionMMobile toothXExtraction(.) (circled)Missing toothXSExtraction, surgicalOPOdontoplastyXSSExtraction, surgical, with sectioning

Oral soft tissues:Oral masses: early detection is critical (see Chapters 29–36).Ulceration, depigmentation (see Chapters 23 and 41).

Periodontal probing (see Chapter 2).

Intraoral radiographs (see Chapter 3).

Charting

Accurately record all variations from normal on chart (Table 1.3). See also Figures 1.11 and 1.12

Dental formulas:Canine permanent: 2 × (I 3/3; C 1/1; P 4/4; M 3/2) = 42Canine deciduous: 2 × (I 3/3; C 1/1; P 3/3) = 28Feline permanent: 2 × (I 3/3; C 1/1; P 3/2; M 1/1) = 30Feline deciduous: 2 × (I 3/3; C 1/1; P 3/2) = 26

Modified Triadan system can be used to identify teeth:Quadrant numbering“100”: upper right quadrant“200”: upper left quadrantFigure 1.11 Canine dental chart.Source: courtesy of Main Street Veterinary Dental Clinic – SVP.“300”: lower left quadrant“400”: lower right quadrantTooth numberingStart at central incisor: “_01”Canines: “_04”Figure 1.12 Feline dental chart.Source: courtesy of Main Street Veterinary Dental Clinic – SVP.Fourth premolar: “_08”Example: right upper fourth premolar, “108”Example: left lower first molar, “309”VariationsFeline: no maxillary first premolar or mandibular first and second premolars, so “first” premolars are “106” and “206” in the maxilla, and “307” and “407” in the maxilla; only first molar present all four quadrantsCanine: no maxillary third premolarDeciduous teeth: “add” 400 to quadrant number – 500 to 800, no deciduous molars, only premolars

COMMENTS

A thorough examination can be performed on every patient in a reasonable amount of time and is essential to detect any abnormalities that may be present.