Contributors: Alex Smithson

 Species: Canine   |   Classification: Miscellaneous

Introduction

  • Clients approaching the veterinary clinic with a specific oral or dental concern for their pet represent only a small proportion of pet owners with animals exhibiting dental disease. The vast majority of oral pathology is 'out of sight, out of mind' and clinical signs may be absent or complex. Malignant changes often go undetected until late stage without regular oral checks.
  • Each tooth may be seen as an individual 'patient' - with 42 teeth in the dog and 30 in the cat, there is a lot to look at. Furthermore, on viewing the oral cavity, only a low percentage of pathology is readily identifiable. It is, therefore, essential that animals receive monitoring on a regular basis and where concern or doubt exists thorough oral evaluation under general anesthesia is advised.
Use the interactive tool from ROYAL CANIN® UK  to explain dog anatomy and disease conditions to your client. Visit ROYAL CANIN Natom Explorer to find out more.​

History and examination

History

  • Thorough history of the patient as a whole is essential, with the mouth forming one part of the whole picture. Animals will rarely show overt signs of oral discomfort unless pain is severe. Signs are often of insidious onset, subtle or fluctuant and missed by owners. Behavioral changes are common but generally attributed to aging or other problems.
  • Signalment (species, breed, age) can also be useful information when making a dental diagnosis.

Examination

  • The whole animal should be assessed, not least because a general anesthetic is required for a full oral investigation. The mouth may act as an indicator for skin disease or compromise, such as renal embarrassment and diabetes. Urinalysis, blood and viral testing may form part of the investigation.
  • The limitations of a conscious oral examination must be emphasized, for every abnormality identified in the conscious patient, a further multiple is likely to be found on thorough investigation of the anesthetized animal. It is important however to assess the occlusion (relationship of the jaws to one another and of the teeth to one another Dental malocclusion ) prior to sedating or anesthetizing the animal.
  • Teeth may be compared to icebergs, with the crown representing the tip and roots the unseen majority. Much pathology is thus hidden by bone and soft tissue and not obvious without detailed examination and investigations.
  • Ensure that soft tissue status (such as gingivitis) and painful pathology (eg fractured teeth Dental fracture ) is not missed in mouths that appear 'clean'. Calculus-caked mouths are often treated preferentially despite in some cases being less urgent as the amount of calculus present is perceived as being an unhealthy mouth. Many teeth are described as 'rotten' or 'decayed' when in fact this is not the case; many are simply coated by gross calculus deposits. It is important to be able to differentiate this and treat accordingly.
  • The conscious oral examination includes a preliminary screening of the teeth for gross abnormalities as well as an examination of the oral soft tissues.
  • The opportunity of dental examination should be taken at every general health check, such as vaccination. Specific clinics are of great benefit and identification of a motivated team member to run these is highly recommended. Ideally a veterinary surgeon along with one or more dedicated veterinary nurses, create a 'dental team' to provide an optimal service.

Oral assessment

  • General anesthesia is required for full oral investigation. This allows each tooth to be examinaed in a thorough systematic way, as well as allowing for further investigations such as intra-oral radiography Radiography: intra-oral parallel and bisecting angle. The soft tissues not visible during the conscious examination, such as tongue, mucosa and tonsils, can also be addessed.

Oral assessment

  • 1.Occlusion assessment:
    • The optimal view is obtained prior to any premedication or anesthetic being given. However if this has not been assessed check the occlusion on induction. The mouth is closed, tongue temporarily tucked back and away from the jaw and teeth relationship is assessed from both lateral and rostral directions Teeth: occlusion assessment. This cannot be accurately achieved with the endotracheal tube normally in place.
      Areas of malocclusion, particularly where teeth contact other teeth or soft tissues, are identified. In young animals, malocclusions should be closely monitored to avoid trauma such as tooth damage and oronasal fistula formation Oronasal fistula.
  • 2.Probe and chart:
    • Once the animal is intubated and stabilized under gaseous anesthesia, detailed oral examination may begin. Initial basic cleaning of the cavity by rinsing with chlorhexidine gluconate mouthwash provides microbe reduction. This reduces the load contacted by the operator - including inhalation on scaling - and potential for bacteremia. Gross calculus may be removed to enable accurate visualization and probing. Ensure that the gingiva is not traumatized whilst doing this as it will result in inaccuracies when examining the mouth. Millimeter-graduated, atraumatic-tipped periodontal probes are inserted into the sulcus, and gently advanced to the point of connection between gingiva and tooth Teeth: periodontal probe 01 Dental instruments.
    • The probe is then moved around the tooths circumference with depth measurements noted. Gingival color and contour is noted and its tendency to bleed scored from 0-3, thereby indicating severity of inflammation. The depth is measured to assess attachment loss. A probing depth of up to 0.5 mm would be considered normal in a cat, whilst up to 3 mm would be considered normal in a large breed dog.
    • For multi-rooted teeth the probe should be tipped perpendicular to the tooth at the level of the furcation - the point at which roots of the same tooth diverge, which is normally bone-filled Teeth: periodontal probe 02.
    • Criteria measured for each tooth include pocket depth, root exposure/gingival recession, furcational bone loss and tooth mobility.
    • The sharp-tipped explorer probe can be used on the tooth surface to identify irregularities, such as fracture lines, resorptive lesions and caries (dental decay).
    • Each quadrant of the mouth is examined systematically, starting with the most mesial (rostral) teeth and working to the posterior aspect tooth by tooth Teeth: multiple, complicated fractures.
    • Oral soft tissues, including the lips, tongue and tonsils are also examined during investigation.
    • All findings are recorded on a dental chart Dental chart. A dental chart is a diagrammatic representation of the mouth and teeth. The teeth are useful as additional location orientators for pathology and abnormality notation. In this manner the chart acts as a 'map' of the mouth and large amounts of information may be accurately and succinctly described Dental assessment: chart. This can be later referred to for monitoring, by colleagues or medico-legal reasons.

Oral radiology

  • Radiography Dental radiography: overview Radiology: dental is as essential a modality in dentistry as it is for other disciplines, such as orthopedics. The roots of each tooth account for approximately 60-70% of the structure of each tooth. The iceberg analogy is obvious, particularly when we consider that most pathology involves the root. Imaging is required to fully appreciate pathology hidden by bone and soft tissue. Sometimes pathology will be seen on the crown, but the full extent of the pathology is only visible with the use of radiography.
  • Minimal investment is required to obtain a dental X-ray machine and small dental films. A standard X-ray machine may be used; however, the multi-directional beam angle and position within the dental theatre of a dental X-ray machine makes intra-oral radiography far more simple and efficient. Intra-oral techniques, including bisecting-angle, must be learnt and practised. Image interpretation also needs to be studied; but the rewards far outweigh the effort as a whole new world is opened up. Without radiography we remain blind to many factors vital to diagnosis and treatment planning.

Recheck and Puppy and Kitten Clinics

Recheck clinics

  • Reminders for rechecks are well received, with frequency of every 3-6 months being appropriate for most patients, depending on factors such as home care and pathology type. This should continue throughout life to maintain close monitoring, reduce advancement of pathology and ensure owners remain educated and motivated towards their pets oral health.
  • The ability and viability of each owner to perform oral hygiene is essential to guide advice and treatment. Where home care is not performed, periodontal disease Periodontal disease is likely to be more difficult to control and other pathologies remain undetected.

Puppy and kitten clinics

  • Assessment of both deciduous and permanent dentition is important Teeth: retained deciduous. Often issues with deciduous teeth will result in abnormality of the permanent set. For example, fractured deciduous teeth develop pulpitis (pulp inflammation) and infection, which may result in damage to the development of the adjacent permanent tooth in addition to the immediate discomfort. of the exposed nerve
  • Many malocclusions noted in immature animals are seen in both permanent and deciduous teeth. This is of a particular concern if there is malposition of the permanent lower canines. A puppy and kitten check at 4-5 months of age (when the permanent canines are erupting) is strongly recommended, to ensure this does not go unchecked. The checks (pre-neutering, for example) at around 6 months of age, commonly identify problems only after trauma has been caused.
  • At 6 months of age all the permanent teeth should have erupted. Other problems such as missing teeth, enamel dysplasia Teeth: enamel disease or persistent deciduous teeth can also be identified at this age.