How to perform a thorough dental exam: Tips from a veterinary surgeon
Periodontal disease is one of the most prevalent disease processes affecting our canine and feline patients.
Most dogs and cats with dental disease don’t come in to see us specifically for that issue — unfortunately, this is often something that clients are unaware of, or they don’t realize how serious a problem it is.
A thorough oral exam is ideally part of every physical, and it allows us to provide an accurate dental grade, make appropriate recommendations on when to do a Comprehensive Oral Health Assessment and Treatment (COHAT), and better prepare clients for what they can expect during that procedure. This, in turn, allows us to provide great patient care and improve the lives of our patients by addressing issues with their oral health.
Performing a thorough oral exam
Proper veterinary dental care starts with a good oral exam! During the exam, I try to visualize all of the teeth, mucosa, and general oral cavity (as long as the patient is cooperative!).
Just like every other part of the physical exam, it’s helpful to develop a system so that you do your oral exam the same way every time — that way, nothing gets missed!
When I’m assessing the oral cavity, I start by lifting the lips on each side to evaluate the canines and premolars. Then I lift up the lips in the front to try to get a good look at all of the incisors. Last, I fully open their mouth to look at the far back molars and at the tongue and palate.
In each area, I’m not only assessing the level of tartar and gingivitis, but I’m also looking for gingival recession, fractures, mobile teeth, missing teeth, malocclusions, and any gingival/mucosal abnormalities like hyperplasia, masses, or ulcerations.
In cats, I also specifically look for resorptive lesions on the crowns. When I find any of these abnormalities, I do my best to show it to the client so that they can actually see the physical changes to their pet’s teeth.
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Assigning a dental grade
It is important to assign a dental grade to each patient. This can help us identify when to recommend a COHAT, and an accurate dental grade can help us prepare owners for what to expect during that COHAT.
- Grade 0: No evidence of tartar or gingivitis
- Grade 1: Very mild gingivitis, mild plaque formation
- Grade 2: Moderate plaque and calculus formation, mild to moderate gingivitis
- Grade 3: Moderate calculus formation, moderate to severe gingivitis
- Grade 4: Severe +/- bridging calculus, severe gingivitis, +/- obviously loose teeth
Patients with dental grades 0 to 1 can be managed with excellent home dental care, like teeth brushing and using products that are proven to be effective to minimize tartar. The Veterinary Oral Health Council website has website pages dedicated to approved products for both dogs and cats.
Patients with dental grade 2 should have a COHAT performed to prevent worsening dental disease, and then ideally have clients continue with home dental care after their procedure.
Patients with dental grades 3 and 4 need a COHAT as soon as possible, and they will almost certainly need extractions.
Increasing dental procedure compliance
A COHAT is an essential part of both preventative care and treatment of dental disease. A properly performed COHAT involves general anesthesia, full mouth dental radiographs, dental probing and charting, evaluation and treatment of any diseased teeth, and finally scaling and polishing all remaining teeth.
Because it is such an involved procedure, there can be significant costs associated with it. It is important to thoroughly discuss the importance of oral health in general and the role of a COHAT with clients so that they understand the value of this procedure.
Poor oral health can have a significant impact on overall systemic health. When dental disease becomes severe (grades 3 and 4), bacteria in that calculus and surrounding the roots of the teeth can gain access to the bloodstream and spread to other organs. As a result, we can see renal disease, liver disease, and cardiovascular disease (2).
Many clients believe that the only issue with their pet’s bad teeth is bad breath — it is crucial for us to help clients understand that dental disease can negatively impact their pet’s overall health.
Encouraging clients to schedule COHAT procedures when their pets are at dental grades 1 and 2 will keep their pet’s teeth healthy longer, result in easier procedures for the veterinarian, and result in a less costly procedure for the owner and easier recovery for the patient.
When clients wait until their pet’s dental grades reach grades 3 and 4, the procedures become significantly more expensive, more difficult, and involve greater recovery time due to dental extractions. Helping clients understand this may improve compliance in scheduling those procedures at grade 2 level, rather than waiting.
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Setting client expectations for dental care
After you’ve completed your oral exam and have recommended a COHAT, it is crucial to communicate what the client can expect from that procedure, both from a medical and a cost standpoint.
When discussing the COHAT with the client, always be clear that most dental disease lies below the gumline where we can’t see it. Even if there are no teeth that obviously need to be extracted based on the physical exam, discuss that you may find diseased teeth on dental x-rays and recommend extracting them — this ensures that the client is not completely surprised if there are some extractions.
Providing an estimate that’s as accurate as possible and preparing an owner for extractions makes for a smoother, less stressful day when you are performing the COHAT.
If the patient has grade 3 or 4 dental disease and you can identify specific teeth that will need to be extracted based on your oral exam, make sure to include those extractions specifically in the estimate! Always include a “high end” budget for additional “surprise” extractions. Don’t forget your nerve blocks, injectable NSAIDs (if appropriate), pain medications to go home, and antibiotics if you think they will be indicated.
Lastly, make sure the client understands that your estimate is truly just an estimate, and that there could be additional costs if there is more dental disease below the gumline than initially expected.
Performing a thorough oral exam will allow you to accurately grade a patient’s dental disease and provide guidance on when to schedule a COHAT.
It is best to recommend a COHAT before patients reach grades 3 and 4 to preserve the health of their teeth and to reduce the risk of systemic health issues secondary to dental disease.
Communicating the benefits and value of a COHAT and preparing the owners for the associated costs will improve owner compliance and allow for better patient care.
Dr. Courtney Norjen is an Associate IndeVet practicing in Virginia and Washington, DC.
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- Veterinary Oral Health Council: http://www.vohc.org/index.html
- Today’s Veterinary Practice “Current Concepts in Periodontal Disease”: https://todaysveterinarypractice.com/dentistry/current-concepts-in-periodontal-disease/