Dental oral exam

Instructor Information

• Name: James Fairs BVSc MSc MRCVS

• Contact: jfairs@rossvet.edu.kn

Learning Objectives

• Personal Protective Equipment (PPE) for Oral Examination - Understand and articulate appropriate PPE, which is crucial for safeguarding veterinary professionals from potential hazards such as bites, scratches, and exposure to infectious agents in saliva and blood during oral examinations.

• Planning and Approach for Oral Examination - Develop a thorough plan for examinations, differentiating between those conducted on a conscious patient and those performed under general anesthesia, recognizing the unique benefits and limitations of each approach.

• Limitations of Conscious Oral Examination - Explain the inherent restrictions of conscious examinations, which typically only allow for a superficial assessment and often fail to detect significant underlying pathology.

• Oro-Dental Anatomy - Accurately identify normal dental and oral anatomy, and competently recognize developmental anomalies or changes indicative of disease.

• Examination Tools - Gain familiarity with essential dental examination instruments, including periodontal and explorer probes, and understand the standardized usage of dental charts for comprehensive documentation.

• Periodontitis and Scoring - Be able to identify the clinical signs of periodontitis (gingival inflammation, tartar, pocket formation, bone loss), and accurately apply mobility and furcation scoring systems to assess the severity of the disease.

• Additional Investigations - Comprehend the necessity and methodology of other diagnostic investigations, such as radiography, and discern when they are required for a complete diagnosis and treatment plan.

Conscious Oral Examination

• Patient History: Critical indicators of dental disease – Meticulously record symptoms such as halitosis, difficulty chewing (dysphagia), favoritism of one side of the mouth, dropping food, pawing at the face, facial swelling, sneezing, or nasal discharge. Document changes in behavior like irritability or reduced activity, and gather information about past dental experiences or treatments.

• Physical Examination: A comprehensive physical examination is essential during a conscious assessment. This includes a thorough head-to-tail evaluation to identify any systemic diseases that could impact oral health or anesthesia. Specific attention should be paid to breed-specific malocclusions, for example, prognathism (Class III malocclusion) in brachycephalic breeds or mandibular brachygnathism (Class II malocclusion) in dolichocephalic breeds, as these can predispose to dental issues.

• Co-Morbidities: Consider any other concurrent health issues. Systemic diseases such as cardiac disease (e.g., valvular disease requiring prophylactic antibiotics), kidney disease (affecting drug metabolism), or endocrine disorders (e.g., diabetes mellitus) can significantly influence the anesthetic protocol and overall patient management before, during, and after dental procedures.

• Diagnostic Laboratory Tests: Pre-anesthetic blood work (complete blood count, serum biochemistry) is crucial to assess organ function and identify any underlying systemic conditions that could increase anesthetic risk. An assessment for heart murmurs, ideally via echocardiogram, is vital to determine cardiac health and guide anesthetic choice, especially in older patients or those with suspected heart disease.

• Specific Concerns for Cats: Assess for calicivirus, Feline Immunodeficiency Virus (FIV), and Feline Leukemia Virus (FeLV). These viral infections can lead to or exacerbate severe oral inflammatory diseases like stomatitis and periodontitis, influencing prognosis and treatment strategies.

Conducting the Conscious Examination

• Patient Amenability Considerations: Carefully evaluate the patient's temperament. If a patient is fractious, painful, fearful, or aggressive, a thorough conscious examination may be impractical or unsafe for both the animal and the examiner. Prioritize patient welfare and consider chemical restraint if a conscious exam is absolutely necessary for initial assessment, though general anesthesia is typically required for a definitive diagnosis.

  • Acknowledgment that conscious examination may be impractical in these cases; prioritize patient welfare.

Examination Staging By Tolerance

• Order of Examination: Adopt a systematic staging of the examination to maximize patient tolerance and efficiency:

  1. Mouth closed: Begin with the least invasive areas: visually inspect the labial (outer) aspects of the premolars and canines.

  2. Mouth closed: Progress to the buccal (cheek side) aspects of the premolars and molars.

  3. Mouth closed: Examine the incisors and canines, checking for plaque, calculus, and gingivitis.

  4. Mouth open: Only when tolerated, proceed to inspect the lingual (tongue side), palatal (roof of mouth side), and occlusal (biting surface) aspects, moving methodically from mesial to distal.

• Client Communication: Ensure clients are fully informed about the significant limitations of a conscious examination, emphasizing that it often only reveals the tip of the iceberg and many pathologies remain hidden without general anesthesia.

Importance of General Anesthesia

• Requirement for In-Depth Examination: General anesthesia is indispensable for a comprehensive and thorough oral examination. Sedation alone is typically insufficient as it does not provide adequate muscle relaxation or pain control for proper probing, charting, and radiographic evaluation, making thorough assessment impossible.

• Pathology Discovery: A significant portion of dental pathology, such as subgingival calculus, periodontal pockets, root resorption, endodontic disease (e.g., root abscesses), and fractured roots, remains hidden and undiagnosed in dogs (and cats) that cannot tolerate a conscious examination. Complete evaluations, including probing and radiography, are simply not feasible without it.

• Lesion Identification Statistics: Research consistently shows that for every single lesion detected during a conscious examination, approximately five additional, often more severe, lesions are identified when a patient undergoes a meticulous examination under general anesthesia, highlighting its critical importance.

Oral Examination Under General Anesthesia (GA)

• Health and Safety Considerations: Awareness of potential hazards during dental procedures under GA is paramount for the safety of the veterinary team:

  • Bites from the animal: Even anesthetized animals can reflexively bite if not properly intubated or if anesthesia is too light.

  • Contact contamination with saliva and blood: Direct contact can transmit bacteria and viruses. Proper barrier protection is crucial.

  • Aerosol contamination from saliva and blood: High-speed instruments generate aerosols that can carry pathogens deep into the respiratory tract. Use of high-volume suction and appropriate masks is vital.

  • Physical harm from flying debris: Scaling and extractions can produce fragments of calculus or tooth material. Protective eyewear is mandatory.

  • Self-inflicted injuries with examination equipment: Sharp probes and instruments require careful handling to prevent accidental punctures or lacerations.

Required PPE for GA

• Health and Safety Guidelines: Essential Personal Protective Equipment (PPE) must be worn by all personnel involved in dental procedures to minimize exposure risks:

  • Scrubs or gowns: Fluid-resistant scrubs or surgical gowns protect clothing and skin from splashes and contamination.

  • Disposable gloves: Nitrile or latex gloves provide a barrier against pathogens. Double gloving may be considered for increased protection.

  • Facemask and goggles or a mask with an attached visor: A combination of a surgical facemask with safety goggles or a full-face shield is necessary to protect the mucous membranes of the eyes, nose, and mouth from aerosols and debris.

  • Engagement of all colleagues involved in the dental procedures: Ensuring every team member understands and adheres to PPE protocols creates a safe working environment and reinforces infection control.

Thorough Examination Under GA

• Examination Opportunities: Every aspect of the oral cavity and surrounding structures must be meticulously evaluated. The period of induction and intubation provides valuable opportunities for initial gross examination prior to the full oral assessment:

  • Epiglottis: Inspect for any inflammation, masses, or abnormalities that could affect airway patency.

  • Tongue: Examine the entire surface, including the ventral aspect (underside) and frenulum, for lesions, masses, foreign bodies, or trauma.

  • Pharynx: Assess the soft palate, tonsils, and posterior pharyngeal wall for inflammation, swelling, or masses that might indicate systemic disease or local pathology.

Benefits of GA Examination

• Examining Safely and Effectively: General anesthesia significantly increases safety for both the operator and the patient by securing the airway with an endotracheal tube (preventing aspiration of fluids) and allowing for precise control of patient movement. This enables a detailed, pain-free examination, which is impossible in a conscious patient.

  • Procedures that become possible under anesthesia include: professional scaling, thorough polishing, surgical extractions of non-vital or severely diseased teeth, and precise biopsy of suspicious lesions without causing stress or pain to the patient.

Pre-Procedure Antiseptics

• Chlorhexidine Wash/Rinse: Application of a 0.12% or 0.2% chlorhexidine gluconate solution as an oral wash or rinse post-anesthesia induction, but before starting dental procedures, helps to significantly reduce the bacterial load in the oral cavity. This creates a safer surgical environment and minimizes the risk of bacteremia.

  • Note on Resistance: Unfortunately, resistance to chlorhexidine has been increasingly reported in various bacterial strains, diminishing its long-term efficacy in some cases.

• Molecular Iodine: Molecular iodine is emerging as a preferred alternative due to its rapid and broad-spectrum antimicrobial action. It is recommended as a superior replacement because it effectively reduces bacterial load within 15 seconds, which is significantly faster than the 60 seconds typically required for optimal chlorhexidine action. Moreover, molecular iodine's effect lasts for at least 72 hours, and resistance has not been reported, making it a highly effective and reliable antiseptic.

Probing and Charting

• Probing Instruments:

  • Periodontal Probe: This instrument has a smooth, blunted, rounded tip and is marked in millimeter (mm) increments. It is designed to gently measure the depth of the gingival sulcus or periodontal pockets around the entire circumference of each tooth, as well as to assess furcation involvement and gingival recession.

  • Explorer Probe: This instrument possesses a sharp, fine tip and is used exclusively for the tactile assessment of hard tissue surfaces. It is ideal for identifying subtle changes in tooth structure that are not visible to the naked eye.

• Charting Requirements: Accurate and meticulous documentation of all intraoral findings is vital for comprehensive dental care:

  • Legal documentation: Dental charts serve as essential legal records, providing a detailed history of the patient’s oral health, diagnoses, and treatments. They are crucial for maintaining professional standards and can be used in case of dispute.

  • Removal of heavy calculus and plaque: It is absolutely essential to remove gross calculus deposits and plaque before accurate periodontal probing can be performed. Calculus obscures subgingival structures and prevents the probe from reaching the base of the sulcus/pocket, leading to inaccurate measurements and missed pathology.

Probing Techniques

• Periodontal Probe Usage:

  1. Clean Bulk Calculus: Ensure all supra- and subgingival heavy calculus is removed to allow unobstructed access to the gingival sulcus.

  2. Probing All Aspects: Methodically probe all six aspects (mesiobuccal, buccal, distobuccal, mesiolingual/palatal, lingual/palatal, distolingual/palatal) of each tooth, carefully examining areas of gingival inflammation or recession.

  3. Methodical Insertion: Gently insert the probe into the sulcus, orienting it parallel to the long axis of the tooth, applying light pressure (0.25 Newtons or the weight of the probe itself). Use a walking motion around the entire circumference of the tooth. Carefully probe around furcation areas, where multi-rooted teeth divide, to assess for bone loss.

Sequential Approach for Examination

• Exam Sequence: A thorough and systematic examination approach using quadrants helps ensure no areas are missed and promotes efficiency:

  • Start with the maxillary right quadrant (Q1) and mandibular right quadrant (Q4).

  • Follow by the maxillary left quadrant (Q2) and mandibular left quadrant (Q3).

  • This typically involves working on one side of the patient before flipping to the other side.

Assessable Factors via Probing

• Clinical Aspects to Assess: The periodontal probe allows detailed assessment of:

  • Gingivitis: Inflammation of the gingiva, characterized by redness, swelling, and bleeding on probing. It is the initial reversible stage of periodontal disease.

  • Periodontal pocket depth: Measurement indicating the destruction of periodontal attachment, where the gingival sulcus has deepened due to apical migration of the junctional epithelium and bone loss.

  • Gingival recession and root exposure: The apical migration of the gingival margin, exposing the tooth root surface, which can lead to sensitivity and further attachment loss.

  • Furcational bone loss: Destruction of alveolar bone in the interradicular space of multi-rooted teeth, indicating significant periodontal disease.

  • Mobility of teeth: Assessment of abnormal tooth movement within the alveolus, an indicator of severe periodontal ligament destruction and bone loss.

  • Fractures and any additional lesions: Gross identification of tooth fractures (especially if extending subgingivally) or other visible oral lesions such as masses or ulcers during the probing process.

Explorer Probe Functions

• Indications for Use: The sharp explorer probe is utilized exclusively on hard tissues (enamel, dentin, cementum) to identify subtle surface irregularities that often indicate significant pathology:

  • Fractures: Detecting hairline fractures, slab fractures, or fractures extending into the pulp chamber.

  • Resorptive lesions: Identifying lytic lesions on the tooth surface, particularly common in felines (Feline Odontoclastic Resorptive Lesions - FORLs).

  • Caries: Locating soft, demineralized enamel or dentin indicative of dental decay.

  • Pulp exposure: Confirming direct communication between the oral cavity and the sensitive pulp chamber, often observed as a dark spot or opening in the center of a fractured tooth, requiring immediate endodontic treatment or extraction.

Charting Findings

• Available Chart Types: Various standardized dental charts (e.g., anatomical, numerical, or combination charts) are available for recording findings systematically. It is essential to record all abnormal findings and document all treatments performed for a complete patient record.

  • Charts should include a clear key with standard notations to ensure consistency and clarity across different veterinary professionals. Common notations include:

    • Fractured tooth: ## (used for fractured teeth that may or may not be pulp exposed)

    • Missing tooth: O (indicating an avulsed or congenitally absent tooth)

    • Extraction: X (denoting a tooth that has been removed previously)

    • Caries: C

    • Resorptive lesion: RL

    • Periodontal pocket depth (in mm): e.g., P5 for a 5mm pocket

Documenting Abnormal Findings

• What to Record: Essential records of specific dental pathologies include:

  • Periodontal disease: Detailed documentation of gingivitis, calculus distribution and severity, pocket depths, attachment loss, and furcation involvement.

  • Missing or damaged teeth: Notation of congenitally missing teeth, avulsed teeth, or teeth with significant structural damage such as fractures, wearing, or malformations.

  • Abscesses: Recording the presence and location of periapical or periodontal abscesses, often associated with swelling or fistulas.

  • Resorptive lesions: Accurate mapping and scoring of feline odontoclastic resorptive lesions (FORLs).

  • Caries and masses: Identification and description of carious lesions (cavities) and any oral masses (e.g., gingival hyperplasia, epulides, neoplastic lesions), including their size, location, and characteristics.

Periodontitis Scoring System

• Sulcus Definition: The sulcus is the normal anatomical space or crevice between the free gingiva (the unattached collar of gingival tissue) and the tooth surface. In a healthy state, this space is shallow and typically less than 1mm.

• Recording Abnormalities: Pocket depth is measured in millimeters (mm) using a periodontal probe. Normal healthy sulcus ranges are critical benchmarks:

  • Canine sulcus: Typically 0-3 mm.

  • Feline sulcus: Typically 0-0.5 mm.

  • Any measurement exceeding these normal ranges indicates a periodontal pocket, signifying attachment loss and periodontal disease.

• Periodontal Attachment Loss Scoring: This system classifies the severity of periodontal disease based on the extent of attachment loss, often confirmed by probing and radiography:

  • 0: Normal – Clinically healthy periodontium with no gingivitis or attachment loss.

  • 1: Gingivitis, no attachment loss (PD0) – Inflammation of the gingiva evident as redness and edema, possibly bleeding on probing, but no evidence of attachment loss or bone resorption radiographically.

  • 2: Early stage (PD1) – Early periodontitis with minimal alveolar bone loss, typically less than 25% of the root length. There is evidence of attachment loss, and gingivitis is usually present.

  • 3: Moderate (PD2) – Moderate periodontal disease with 25-50% attachment loss, often accompanied by moderate to severe gingivitis, noticeable pocket formation, and moderate radiographic bone loss.

  • 4: Advanced (PD3) – Advanced periodontal disease with significant attachment loss, greater than 50% of the root length. This stage is characterized by deep periodontal pockets, severe gingivitis, substantial radiographic bone loss, and often tooth mobility, furcation exposure, and gingival recession.

Furcation Scoring System

• Furcation Involvement Assessment: This system evaluates the extent of bone loss around the roots of multi-rooted teeth, indicating chronic, severe periodontitis and often a guarded to poor prognosis for the affected tooth:

  • 0: No furcation involvement (F0) – No detectable bone loss in the furcation area; the probe cannot enter the space between the roots.

  • 1: Incipient furcation involvement (F1) – The periodontal probe tip extends horizontally less than 50% under the crown into the furcation area, showing early attachment loss, but does not pass completely through. Bone loss is minimal in this area.

  • 2: Partial furcation involvement (F2) – The probe extends horizontally greater than 50% under the crown into the furcation area, indicating localized, significant attachment loss, but it still does not pass completely through from buccal to lingual/palatal. There is significant interradicular bone loss.

  • 3: Complete furcation involvement (F3) – The probe extends completely through the furcation from the buccal side to the lingual or palatal side, meaning the interradicular bone has been entirely destroyed. This indicates severe, advanced periodontal disease with a very poor prognosis for tooth retention.

Mobility Scoring System

• Assessment of Tooth Movement: This system quantifies the degree of abnormal tooth movement, which is a key indicator of the severity of periodontal ligament destruction and alveolar bone loss. Mobility is assessed by gently applying pressure to the tooth with two instrument handles (e.g., probe handles).

  • 0: Normal (M0) – No detectable mobility; the tooth is firmly anchored in the alveolus.

  • 1: Slight mobility (M1) – Horizontal movement less than 1mm in any direction. This often suggests early loss of periodontal support.

  • 2: Moderate mobility (M2) – Horizontal movement greater than 1mm in any direction. This indicates significant periodontal ligament and bone loss, and the prognosis for retaining the tooth is guarded.

  • 3: Severe mobility (M3) – Both vertical and horizontal movement, or in multi-rooted teeth, horizontal movement greater than 1mm accompanied by vertical movement. This signifies severe to end-stage periodontal disease, often requiring extraction as the tooth has lost most of its structural support.

Importance of Accurate Charts

• Benefits of Charting: Meticulous and accurate charting provides numerous benefits for patient care, practice management, and professional accountability:

  • Ensures efficiency: Detailed charts allow for quicker re-evaluation during subsequent visits, saving time compared to reconstructing extensive notes from memory.

  • Establishes a permanent record of dental health: Provides a comprehensive and chronological history of the patient's oral condition, including baseline assessment, disease progression, and all treatments rendered.

  • Education for clients and colleagues: Charts are valuable tools for educating clients about their pet's dental health status and proposed treatments (e.g., visually demonstrating problem areas). They also facilitate clear communication among veterinary team members.

  • Aids in ongoing monitoring of dental conditions: Allows for tracking the progression of periodontal disease, the success of treatments, and the identification of new or recurring issues over time.

  • Serves as legal documentation: Provides incontrovertible evidence of the care provided, adhering to regulatory requirements and protecting the practitioner in legal contexts.

Other Oral Lesions

• Action on Other Lesions: Any other suspicious or uncommon lesions detected during the oral examination, such as masses, ulcers, or unusual discolorations, should be thoroughly documented with detailed descriptions and photographic evidence. A biopsy (incisional or excisional) should be performed to obtain a definitive histopathological diagnosis, especially to rule out neoplastic processes, which is crucial for appropriate treatment planning and prognosis.

Small Animal Dentistry: Radiography

• Instructor Information:

  • Name: James Fairs BVSc MRCVS

  • Contact: jfairs@rossvet.edu.kn