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Veterinarian Technician February 2009 (Vol 30, No 2)

Dental Checkup — Charting Oral Pathology in the Dog

by Jeanne Perrone, CVT, VTS (Dentistry)

    In many general practices with dentistry profit centers as well as in veterinary clinics with board-certified dentists, technicians may perform the initial oral examination and, in the process, may note pathologic findings to relate to the veterinarian. Because a pathologic finding may be as simple as mild gingivitis or as complicated as suspected amelanotic melanoma, it is advantageous for technicians to understand oral pathology and terminology so they can discuss significant findings with the veterinarian and accurately record the veterinarian's diagnostic conclusions and protocols accordingly.

    The Basic Dental Chart

    If your clinic is not using a dental record — referred to as the dental chart — it is time to start. The dental chart is a written report that uses a diagram and short- and long-hand notations to describe the oral examination, diagnostic data, and treatment measures. The layout of the chart should be user-friendly for all staff members involved with the dental examination.

    The dental chart typically includes a diagram depicting one or more views of the patient's dentition. Figure 1 shows a dental chart that includes both lateral and open-mouth views of canine dentition. The purpose of the dental chart is to allow the examiner to indicate the exact location of the pathology for each affected tooth and surrounding tissue. Notations on the dental chart can be made using abbreviations (Figure 1 and Figure 2), but these may vary, so it is important that the dental record identifies the abbreviation key used in case the patient is referred to another clinic for treatment. Figure 3 reviews some of the oral and directional nomenclature that is important to memorize. In addition to identifying pathology on specific teeth by abbreviation, lesions (e.g., oral tumors) that encompass a large area can be identified by simply circling the affected area (Figure 4) or drawing a separate image that shows the extent of the pathology.

    When learning how to chart oral pathology properly, the technician needs to be familiar with oral anatomy, including root canal and root apex, gingiva, alveolar mucosa and alveolar bone, pulpal chamber, cementum, and enamel (Figure 5 and Figure 6). In addition to helping the technician complete the chart accurately, this knowledge plays a role when the technician has to translate the dentition chart findings to the patient's general medical record and/or to a form that needs to be completed for further laboratory testing.

    Common Pathology Findings

    Gingival health reflects the general condition of the whole mouth. The degree of gingivitis is noted as mild, moderate, or severe using the abbreviation GI, GII, or GIII, respectively. The level of plaque calculus also is a general condition reflecting the overall health of the mouth and is noted on the dental diagram as slight, moderate, or heavy using the abbreviations C/S, C/M, or C/H, respectively.

    Missing teeth — teeth that have been previously removed (extracted), fallen out, impacted below the gum line, or never developed — are either colored in or circled on the dental diagram. Dental radiography and a good medical history can confirm the site of any missing teeth.

    Abnormal pocket depths are important to identify because they help determine the extent of periodontal disease. The depths are found and measured by gently inserting a periodontal probe into the gingival sulcus. Any abnormal depths are identified on the dental diagram by indicating the millimeter depth next to the tooth in question (on the aspect of the tooth where it was found); see PP2 notation on the Canine Dental Chart in Figure 2, which identifies a periodontal pocket of 2 mm. The normal pocket depth in a dog is <3 mm and in a cat is <0.5 mm.

    Mobile teeth can be identified by touching the top of the tooth with the periodontal probe and attempting to move the tooth. There are three grades of mobility: M1 means there is <1 mm of side-to-side movement, M2 reflects 1 mm or more side-to-side movement, and M3 means there is more than 1 mm of side-to-side movement as well as up and down in the socket.

    Gingival recession is shrinking of the free gingiva in the presence of bacteria, plaque, and dental calculus. Using the periodontal probe, the technician can measure the area of recession from the cementoenamel junction to the gingiva; on the dental diagram, it should be noted as GR, along with the millimeters of recession.

    Gingival hyperplasia is the excessive growth of gingival tissue, which causes false pockets. With the periodontal probe, the technician can measure the false pocket from the top of the hyperplastic tissue to where the free gingiva would start. Gingival hyperplasia should be noted as GH on the dental diagram, along with the millimeters of hyperplasia present.

    The furcation is the area between the roots where they join the crown. Using the periodontal probe, the technician should gently insert it into any exposed furcation. There are three designations for furcation: F1 means the furcation can just be detected by the probe, F2 means the probe can pass halfway into the furcation, and F3 means the probe can pass all the way through the furcation to the palatal or lingual aspect of the tooth.

    The term fracture applies to a tooth, tooth root, or the jaw itself and is identified on the dental diagram as FX. Fracture with pulp exposure, noted as FX PE, is a broken tooth with exposure of the pulp, as noted in the dental diagram depicted in Figure 2. The pulp is located within the center of the tooth and is made up of the blood vessels and nerves. When the pulp is exposed, the tooth is exposed to opportunistic bacteria and debris in the environment.

    Discolored teeth can occur from normal aging changes or from trauma. If trauma has occurred, the pulp can bleed and cause discoloration. The discoloration is usually pink to purple, similar in color and appearance to a bruise.

    An oral mass is any excessive abnormal growth of tissue. A mass may be malignant or benign. Although they can be identified as OM on the dental diagram, masses are usually drawn to show their exact location and the amount of coverage (see Figure 4). The texture, color, and size of the mass are then identified by long-hand on the dental chart. All oral masses should be examined thoroughly by the veterinarian, and the definitive diagnosis should be determined by a veterinary pathologist.

    Any softness on the enamel because of caries can be detected by using an explorer. Caries, noted as CA, are usually seen on the occlusal surface of premolar 4 and the molars.

    Formerly called resorptive lesion, the term tooth resorption was recently adopted by the American Veterinary Dental College, although for the purpose of charting, RL can continue to be used. Tooth resorption, which is commonly found in cats but also can occur in dogs, involves a loss of tooth structure that results when cells called odontoclasts are activated and turn tooth roots into bone, causing the crown to fall off. The cause associated with activation of odontoclasts is unknown. Tooth resorption is graded on levels I to V, depending on the depth of resorption into the tooth and degree of crown destruction present: RLI means that enamel only is affected; RLII involves enamel and dentin; RLIII involves enamel, dentin, and pulp; RLIV indicates that part of the crown is missing; and RLV means there is no crown visible but the root tips remain.

    As shown in this brief review of important oral anatomy and pathology, a patient's dental chart can provide an in-depth picture of the oral cavity. For that reason, it is important that the technician examine each tooth individually and chart abnormal findings to be discussed with the veterinarian. This knowledge also is useful when reviewing various treatment recommendations with the owner.

    For More Information:

    American Veterinary Dental College; www.avdc.org.

    Gorrel C, Derbyshire S. Veterinary Dentistry for the Nurse and Technician. London, England; Butterworth-Heinemann Medical; 2005.

    Kesel ML. Veterinary Dentistry for the Small Animal Technician. Hoboken, N.J.; Wiley, John & Sons; 2000.

    Lobprise H. Blackwell's Five Minute Veterinary Consult Clinical Companion: Small Animal Dentistry. Oxford, U.K.: Blackwell Pub Professional; 2007.

    Tutt C. Small Animal Dentistry. Oxford, U.K.: Blackwell Pub Professional; 2006.

    Wiggs RB, Lobprise H. Veterinary Dentistry: Principles and Practice. Baltimore, Md.: Lippincott, Williams & Wilkins; 1997.

    NEXT: Editor's Letter — Is Anesthesia-Free Dentistry Really an Option?


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