Dentistry encompasses conditions of all structures of the oral cavity, namely teeth (hard tissues and periodontium), oral mucosa, salivary glands etc. Some conditions can be managed successfully in general practice and some need referral to a specialist for treatment. The general practitioner needs to recognize the conditions, be able to perform a full diagnostic workup, realise the clinical significance of the findings and institute treatment (in-house or referral) as required.

Oral conditions and diseases are a diagnostic challenge. Several disease conditions are generally present simultaneously. The great majority of dogs and cats will have gingivitis and or periodontitis as well as other problems. Moreover, clinical signs are rarely specific, i.e., malodour, changing in eating patterns, and dysphagia are indications that there is a problem in the oral cavity, but they are not necessarily specific for a particular disease. Finally, manifestations of disease are often discrete and are often not detected on conscious clinical examination. Even if they are detected on conscious examination, general anaesthesia is required to evaluate the extent of pathology. The importance of a full oral exam under general anaesthesia (definitive examination) cannot be underestimated.

The recommended protocol for definitive examination of the oral cavity¹ involves inspection of the oropharynx, lips, cheeks, oral mucous membranes, hard palate, floor of the mouth, tongue as well as teeth and periodontium. In general veterinary practice examination of the periodontium is often omitted and periodontal disease is missed.

The periodontium of each tooth needs to be assessed to:

1.  Identify the presence of periodontal disease (gingivitis and periodontitis)

2.  Differentiate between gingivitis (inflammation of the gingiva) and periodontitis (inflammation of the periodontal tissues resulting in loss of attachment and eventually tooth loss)

3.  Identify precise location of disease processes

4.  Assess the extent of tissue destruction where there is periodontitis

The following periodontal indices and criteria should be evaluated for each tooth:

1.  Gingivitis and Gingival Index
The presence and degree of gingivitis is assessed based on redness, swelling and presence or absence of bleeding on probing of the gingival sulcus. Various indices can be used to give a numerical value to the degree of gingival inflammation present. In the clinical situation, a simple bleeding index is the most useful.

2.  Periodontal Probing Depth (PPD)
PPD measures the depth of the sulcus. A graduated periodontal probe is gently inserted to the base of the gingival sulcus, i.e., until resistance is felt. The depth from the free gingival margin to the base of the sulcus is measured in mm at several locations around the whole circumference of the tooth. The probe is moved gently horizontally, walking along the floor of the sulcus.
The gingival sulcus is 1–3 mm deep in the dog and 0.5–1 mm in the cat. Measurements in excess of these values usually indicate the presence of periodontitis when the periodontal ligament has been destroyed and alveolar bone resorbed, thus allowing the probe to be inserted to a greater depth. The term used to describe this situation is periodontal pocketing. All sites with periodontal pocketing should be accurately recorded. Gingival inflammation resulting in swelling or hyperplasia of the free gingiva will, of course, also result in measuring sulcus depths in excess of normal values. In these situations, the term pseudo-pocketing is used, as the periodontal ligament and bone are intact (i.e., there is no evidence of periodontitis) and the increase in PPD is due to swelling or hyperplasia of the gingiva.

3.  Gingival Recession
Gingival recession is the distance (in mm) from the cemento-enamel junction to the free gingival margin. It is also measured using a graduated periodontal probe. At sites with gingival recession, PPD may be within normal values despite loss of alveolar bone due to periodontitis.

4.  Furcation Involvement
Furcation involvement refers to the situation where the bone between the roots of multirooted teeth is destroyed due to periodontitis. The furcation sites of multirooted teeth should be examined with either a periodontal probe or a curved dental explorer.

5.  Tooth Mobility
Assessed using a suitable instrument, e.g., the blunt end of the handle of a dental mirror or probe
Should not be assessed using fingers directly, since the yield of the soft tissues of the fingers will mask the extent of tooth mobility

6.  Periodontal/Clinical Attachment Level (PAL/CAL)
Periodontal attachment level records the distance from the cemento-enamel junction (or from a fixed point on the tooth) to the base or apical extension of the pathological pocket. PAL can be measured with a periodontal probe. It can also be calculated, i.e., PPD + gingival recession/PPD - gingival hyperplasia. PAL/CAL is a more accurate assessment of tissue loss in periodontitis than PPD.

The information resulting from the examination (and any treatment performed) needs to be recorded. A basic dental record consists of written notes and a completed dental chart. Additional diagnostic tests and radiographs are included as indicated. A dental chart is a diagrammatic representation of the dentition, where information (findings and treatment) can be entered in a pictorial and/or notational form. It provides a simple way of recording most of your findings and treatments. However, it is only a chart and needs to be supplemented by clinical notes, radiographs, etc. to make a complete dental record.

The definitive oral examination, supplemented by radiographs will give a complete picture of the disease processes present and allow for targeted treatment. Clinical cases will be used to exemplify this approach.

References

1.  Gorrel C. Oral examination and recording. In: Gorrel C. Small Animal Dentistry. Saunders Elsevier. 2008:13–21.