6 steps to the correct diagnosis of oral and dental diseases

Oral examination should be a part of every physical examination in dogs and cats, just as a full physical examination should be performed in animals that are presented due to presumed oral/dental disease. However, detailed oral examination can only be performed under general anaesthesia and here are the 6 steps, how to reach the correct diagnosis and make a treatment plan.

1. If the animal allows it, lift the lip

During the examination of an awake animal, the extra-oral structures should be examined first (e.g., the facial and skull bones, masticatory muscles, temporomandibular joint, the regional lymph nodes, salivary glands, nose).

If the patient allows it, with its mouth held closed, the lips on both sides of the oral cavity are lifted to examine the mucocutaneous junction, buccal mucosa, gingiva and the buccal surfaces of the teeth. The occlusion is checked, and any missing teeth or dental fractures noted. Plaque and calculus are briefly evaluated, together with gingivitis and any signs of advanced periodontal disease. Lastly, the mouth of the animal should be gently opened, if the animal allows it, and the lingual aspect of the teeth, tongue, hard palate, and oropharynx inspected.

The purpose of the awake oral examination in animals is merely to estimate the extent of the oral/dental disease(s), thus enabling a clinician to formulate a dental treatment plan and provide the client with a cost estimate.

2. Place the patient under general anaesthesia

A detailed pre-anaesthetic examination is completed and the animal placed under general anaesthesia, if the patient is a good candidate for it. A detailed oral and dental examination can only be performed with the animal under general anaesthesia. During dental charting and periodontal probing, a detailed examination of dental and periodontal tissues is performed on a tooth-by-tooth basis with a periodontal probe (periodontal tissue examination) and a dental explorer (hard dental tissue examination). There may be additional pathologies found during the detailed oral and dental examination, which may also influence the final costs of the procedure – keep in contact with the client over the phone for all updates.

3. Thoroughly examine the whole oral cavity

Firstly, oral mucosa, hard and soft palate, oropharynx and floor of the mouth are examined, the tongue palpated and teeth counted. All abnormalities are noted in the dental chart.

4. Perform periodontal probing

With our periodontal probe we step-by-step examine all of the following:

#1: For clinical purpose, evaluation of dental deposits (plaque and calculus – which is calcified material on the tooth surface that cannot be removed by a periodontal probe) is not critical. Animals with severe dental deposits may have minimal periodontal disease and vice-versa.

#2: Mobility describes the distance a tooth can be moved within the alveolus (stage of 0 –3) and indicates the amount of attachment loss.

#3: The gingival index describes findings associated with gingival inflammation (0 indicates healthy gingiva to 3, which indicates severe inflammation, severe erythema, spontaneous bleeding, and some ulceration).

#4: To examine the probing depth, a probe is inserted gently under the gingival margin, parallel to the long axis of the tooth and advanced to the base of the sulcus or pocket. The distance between the gingival margin and the bottom of the sulcus or pocket is measured at 6 sites around each tooth and referred to as the probing depth. In the periodontally healthy individual, the sulcus depth is 0.5 to 1 mm in small dogs and cats, and 1 to 3 mm in medium and large dogs. Any gingival recession or gingival enlargement should also be measured and calculated from this measurement to determine the clinical attachment loss.

#5: The stage of furcation involvement or exposure indicates bone loss in the furcation area (area between the roots in multirooted teeth). The probe is gently run around the cervical area of the tooth, and any intedation in the areas of furcations are noted and measured. If there is no furcation involvement, the tooth is assigned stage 0. Furcation involvement for which a periodontal probe extends less than half-way under the crown in any direction of a multirooted tooth with attachment loss is assigned stage 1; furcation involvement for which a periodontal probe extends greater than half-way under the crown of a multirooted tooth with attachment loss, but not through and through is assigned stage 2; furcation exposure for which periodontal probe extends under the crown of a multirooted tooth, through and through from one side of the furcation out the other is assigned stage 3.

5. Perform dental charting

A dental explorer is then used to examine any existing dental fractures; the most important is to evaluate dental pulp involvement, to diagnose external resorption lesions and (rarely) caries, and to examine the texture of the root surfaces, if exposed (resorption, fractures, calculus).

6. Complete the examination with full-mouth dental radiographs

Once all the parameters are measured and noted on the dental chart, these findings are compared to and combined with radiographic findings on a tooth-by-tooth basis. Once a diagnosis is achieved for each tooth, a treatment plan is made, and the client contacted (by telephone) to obtain final informed consent to perform all treatments that are in the best medical interest of the animal. Then routine periodontal treatment is performed, and any additional problems addressed as necessary.

Check out a clinical case we published in Clinician’s brief, which shows the importance of a detailed oral examination and dental radiography in establishing a diagnosis and planning the treatment.

If you have noted any problems with your animal, please consult your veterinarian.

Selected references
1. Boyce EN, Logan EI (1994). Oral health assessment in dogs: study design and results. J Vet Dent 11(2):64-70.
2. Crossley DA (1995). Tooth enamel thickness in the mature dentition of domestic dogs and cats–preliminary study. J Vet Dent 12(3): 111-113.
3. DuPont G, DeBowes LJ (2009). Atlas of dental radiography in dogs and cats. St. Louis: Saunders Elsevier.
4. Evans HE, de Lahunta A (2013). Miller’s anatomy of the dog. 4th ed. St. Louis: Elsevier Saunders.
5. http://www.avdc.org/nomenclature.html
6. Logan EI, Boyce EN (1994). Oral health assessment in dogs: parameters and methods. J Vet Dent 11(2):58-63. Erratum in: J Vet Dent 1994;11(4):133.
7. Nanci A (2008). Ten Cate’s oral histology. Development, structure and function. St. Louis: Mosby Elsevier.
8. Peralta S, Verstraete FJ, Kass PH. Radiographic evaluation of the types of tooth resorption in dogs. Am J Vet Res 2010;71(7):784-793.
9. Verstraete FJ, Kass PH, Terpak CH (1998). Diagnostic value of full-mouth radiography in cats. Am J Vet Res 59(6):692-695.
10. Verstraete FJ, Kass PH, Terpak CH (1998). Diagnostic value of full-mouth radiography in dogs. Am J Vet Res 59(6):686-691.
11. Verstraete FJM (2011). Small animal dentistry syllabus VSR413 – winter 2011. Davis: Department of surgical and radiological sciences, School of veterinary medicine, University of California-Davis.
12. Wolf HF, Rateitschak EM, Rateitschak KH, Hassel TM (2005). Color atlas of Dental Medicine: Periodontology. 3rd ed. Stuttgart: Thieme.