The dental chart: The oral roadmap (Proceedings)

Periodontal disease is progressive-the dental chart tracks how a patient is progressing (or not) from cleaning to cleaning.  The dental chart is a permanent record of a patient's dental care and should include:  exam of the oral cavity, tooth by tooth exam, pathology found in the oral cavity, radiographic finding, treatment performed, and home care instructions.

The dental chart is the “blueprint” for treatment of the patient and should be a complete record to refer to from one procedure to the next.  It should be organized and comprehensive in a simple, easy to read format.  Abbreviations should be used to minimize writing and save time.  A complete list of approved abbreviations are available from the American Veterinary Dental College and can be found on the website at www.avdc.org. 

The complete dental examination starts with the physical exam with the patient before sedation.  Any changes in facial structures, ie. swollen face, muzzle, eyes, etc. should be noted.  The occlusion should also be evaluated during as well.  It is extremely difficult to properly assess a malocclusion in an anesthetized patient due to the endotracheal tube preventing the mouth from being closed completely.  A complete pain evaluation should also be performed at this time if possible.  If the patient will allow, the pain evaluation is performed by palpating the muzzle, opening and closing the mouth, and digital pressure on any abnormal areas on the gingiva.

A Class 1 Malocclusion is indicated when 1 or more teeth are malpositioned.  It is common in brachycephalic patients to have rotated maxillary premolars.  This would be an example of a Class 1 malocclusion.  Another common example of a Class 1 malocclusion would a “lance tooth” canine that is often seen in Shetland Sheepdogs.  The canine tooth points toward the nose instead of its normal position.  The AVDC abbreviation is noted by the following:  Mal/1/MV.

The next group of classifications pertain to the relationship between the maxilla and mandible.  There are several dental issues that can occur when these structures are not aligned or one is shorter than the other.  In many cases, these conditions are considered congenital.  In some cases, early intervention is recommended and can possibly avoid later dental problems.  Interceptive orthodontics is a term used to describe certain treatment plans to correct some orthodontic issues.  The mandible and maxilla normally grow independently of each other during a puppy's development.  There is a condition known as dental interlock.  This occurs when the mandibular teeth lock with the maxillary teeth and prevent the jaw from growing any further.  By extracting the involved teeth, this interlock can be eliminated, allowing the jaw to grow at its normal rate and eventually produce a normal occlusion.  However, in more severe cases, the occlusion can't be corrected, and intervention is required to prevent trauma.

A Class 2 Malocclusion is characterized by the mandible being shorter than the maxilla. The degree of malocclusion can be mild to severe.  In more severe cases, the mandibular incisors will make contact with the soft palate and cause trauma.  This is when surgical intervention is necessary.  Treatment options may include odontoplasty and bonding of the mandibular incisors to eliminate trauma if they are just touching the palate.  Extractions are required when the incisors are contacting enough to actually puncture the palate.  The abbreviation is noted as Mal/2.

A Class 3 Malocclusion occurs when the maxilla is shorter than the mandible.   Typically, the maxillary incisors will cause trauma to the floor of the mouth.  Treatment options include odontoplasty or extractions.  The abbreviation is noted as Mal/3.

A Crossbite can be classified as rostral or caudal and affects either the incisor alignment or the molar alignment.

The charting process itself should be done the same way each time for consistency.  This will prevent areas being missed.  The quadrants should be done in the same order.  The triadan numbering system is used to speed up the process as opposed to using the anatomical notations.  The triadan numbering system can be mastered easily if used consistently.  Each quadrant is assigned a “100” number, and each tooth then is assigned a single number.  The numbers get larger as the teeth move away from the midline.

The right maxilla are the “100's”.  Starting at the right central incisors, they are numbered as 101, 102, 103.  The right maxillary canine is 104, the right maxillary 1st premolar is 105 and so on.  Moving in a clockwise direction, the left maxilla is noted as “200's”, left mandible is noted as “300's”, and the right mandible as the “400's”.  Charting can be done using a two or four handed technique.  A four handed technique is preferred as it reduces the time to chart the oral cavity.  This technique is achieved by having one person assessing the oral cavity and a second person making the notations on the chart as the pathology is found and communicated.

Directional terms are used to indicate specific areas of the oral cavity or of individual teeth.  Mesial and distal are used when noting individual teeth.  Areas that are toward the midline are noted as mesial.  Away from the midline is distal. In the maxila there are 2 terms used to indicate direction.  Buccal refers to areas toward the cheek, and palatal is toward the palate.  In the mandible, lingual is used to indicate any area toward the tongue and labial is toward the lips. Rostral (toward the nose) and caudal (toward the back) are used for indicating direction within the oral cavity itself.

Stage versus index when used in the charting process.  Stage is the assessment of the extent of pathological lesions in the course of the disease that is likely to progress.  For example, the term “stage” is used when noting periodontal disease.  Index is a quantitative expression of predefined diagnostic criteria whereby the presence or severity of pathological conditions are recorded by assessing a numerical value.  This term is used when denoting the amount of plaque or gingivitis.

Specific instrumentation and equipment is necessary to perform a comprehensive oral assessment.  A periodontal probe/explorer is used to measure periodontal pocket depths, or to detect any enamel defects present.  Normal sulcal depth on a canine patient is 1.0-3.0mm and 0.5-1.0mm on a feline patient.  The proper lighting and magnification is absolutely required when working in the oral cavity.  Oral radiology is also a required component in order to properly assess pathology above the gumline.  Changes in bone structure as well as other pathologies can only be found if radiographed. 

A comprehensive dental chart is also used and should allow enough space to place diagnostic and treatment abbreviations on individual teeth, as well as, a space for radiographic findings, follow up care, etc.

Common pathologies

Periodontal changes should be noted including attachment loss, bone loss, furcation exposure, and mobility. Attachment loss is measured from the cementoenamel junction to the apex.  Furcation exposure is staged using a periodontal probe.  Mobility is measured in millimeters based on the movement of the tooth. 

Tooth fractures have several classifications.  An uncomplicated crown fracture (UCF)is indicated by a crown fracture that does not involve the pulp chamber.  A complicated crown fracture (CCF) is noted when the pulp chamber is open.  Other classifications of tooth fracture include uncomplicated crown-root fracture (UCRF), complicated crown-root fracture (CCRF), and root fracture (RF)

Tooth resorption also has several classifications and abbreviations ranging from mild enamel loss (TR1), to complete crown loss (TR5). 

Other common pathologies found in the oral cavity include gingival hyperplasia (H), tooth abrasion or wear patterns (AB), oral nasal fistual (ONF), stomatitis (ST), oral masses (OM).  Cavities (CA) in dogs aren't commonly seen, but should always be noted on the dental chart.

Radiographic findings are noted on the dental chart.  Horizontal bone loss or vertical bone loss is recorded where applicable, as well as apical lucencies.  Other anomalies that can be found include root fractures, impacted teeth (T/I), and abnormally formed teeth.  

Common treatment modalities are also noted using the AVDC abbreviations.  Open root planing (RPO) and closed root planing (RPC) are techniques used to treat early to advance stages of periodontal disease in order to reduce pocket depths to prevent tooth loss.  Simple (x) and surgical (xss) extractions are also noted. 

A complete dental chart is essential in making a complete record to diagnose, treat, and monitor the patient's oral conditions.