Veterinary dentistry is not just about cleaning teeth or getting rid of bad breath in pets. Periodontal disease is the top disease diagnosed in both dogs and cats, with 80% of pets over the age of three having some stage of periodontal disease. Dental procedures are an important aspect of well-rounded vet care, so all aspects of veterinary dentistry should be treated just as highly as other valued procedures. A dental procedure is an anesthetized procedure that requires trained and educated veterinarians and veterinary technicians. Dentistry should be treated with as much care and attention as any other anesthetized procedure that takes place in the veterinary hospital. Only veterinarians can diagnose disease, but the veterinary technician plays a key role in assisting the veterinarian. The veterinary technician aids by obtaining an accurate history, recognizing pathology, and bringing this information the doctors’ attention. The veterinary technician also assists by providing the initial workup, probing, charting, scaling, and polishing. They also take all diagnostic radiographs and administer nerve blocks, proving just how many roles the technician has during these procedures. The veterinary technician can be trained in all aspects of a thorough dental procedure, and this includes performing a proper and thorough dental cleaning, obtaining diagnostic dental radiographs, and performing nerve blocks. With the prevalence of periodontal disease in dogs and cats, every patient should be receiving routine dental care. The following outlines the steps of the dental procedure day.

The Pre-anesthetic Exam
You should first start by obtaining an oral history and performing an oral exam. This includes looking for and asking the owner about the following: bad breath, swollen, red, or bleeding gums, excessive drooling, changes in eating or chewing habits including dropping food, going to the food but not eating, vocalizing while eating, tooth loss, and disinterest in toys. Pets do not typically show signs of pain or discomfort, so these questions are essential for better understanding your patient. You should also find out what the pet prefers to chew on at home, as well as any at home dental care the client is offering. A patient may avoid a toy or a particular food due to the pain they are experiencing, and the owner may perceive this as the pet not liking that item anymore. Common clinical signs of oral disease that may be noted on a conscious oral exam include halitosis, malocclusions, persistent deciduous teeth, plaque and calculus, missing teeth, and signs of periodontal disease such as gingival recession or mobility. Running blood work is essential. Many of our patients are geriatric, so we need to make sure there is not underlying disease that could complicate their procedure and recovery. Age is not a disease in itself, but age can predispose our patients to having coexisting disease. Ideally, lab work should be performed before the day of the procedure in case there are abnormalities found. Having the lab work completed ahead of time will prevent a procedure from being cancelled the day of surgery due to abnormalities. This will also allow the patient to be treated for the abnormalities ahead of time, and allows that patients’ protocol to be tailored to fit their needs. A chemistry panel, complete blood count (plus or minus coagulation panel), urinalysis, chest radiographs, echocardiogram, ECG, and blood pressure should be considered for evaluation.

Protecting yourself
Personal Protection Equipment (PPE): Wear eye protection! Goggles, loupes, or a visor should be worn by everyone in the operatory area as pieces of calculus, tooth, bone, blood, saliva, and even broken burs become airborne and can cause an eye injury or infection. Surgical face masks that cover mouth and nose should be worn. Anti-fog masks are helpful in preventing protective eye wear from fogging up. Appropriately fitted gloves and protective clothing such as a gown or lab coat, as well as surgical caps should be worn to prevent bacterial contamination of clothing and hair. You should also consider hearing protection if the noise of the dental unit running is bothersome. Ergonomics is an applied science concerned with designing and arranging the items people use in the most efficient and safe way possible. Dentistry has a lot of small and repetitive movements that can strain our muscles, tendons, and ligaments. To protect ourselves from fatigue and short- or long-term injury, we should practice the best ergonomics possible. Adjust the table to fit the individual, allowing arms to be parallel with the table. A dental saddle seat allows one to sit with a straight back, their thighs slightly angled to the floor, and their gaze looking down without bending over. Utilizing a modified pen grasp when holding instruments reduces strain of repetitive movements. Fatigue mats can be used if one is standing for prolonged periods of time.

Steps to the Complete Oral Exam and Charting
The complete oral exam should be performed in a systematic manner with the patient under general anesthesia. It is recommended than an oral exam under anesthesia should be performed on an annual basis for all patients and annual cleanings are usually performed at the same time. When communicated with pet owners about the importance of having the teeth cleaned, the oral exam should be emphasized as well. Our goal is to find pathology, treat what needs to be treated, and prevent disease. We need to shift our emphasis of cleaning the teeth when they look dirty or extracting teeth when they are falling out, to preventing disease from getting that bad in the first place. The oral exam is as or more important than the cleaning. There should be a qualified technician monitoring anesthesia and a qualified technician performing the dental procedure. It is not safe for one technician to be doing both. Neither job can be performed correctly or safely if one person is doing both. Start with a pre-intubation exam. Check the occlusion of the patient before intubation.

Once the patient is intubated, the endotracheal tube will prevent the mouth from closing. Take photographs of the occlusion so there’s reference to look at if attrition or soft tissue trauma is found on the complete oral exam. Once the patient has been anesthetized, the oral exam and charting can begin. Using four handed dentistry, the doctor performs a complete oral exam using the probe/explorer and the technician documents the findings. A technician educated in veterinary dentistry can be trained to perform a complete oral exam; however, a veterinarian must diagnose pathology and check the findings. A dental chart is legal, medical documentation and is part of the legal medical record for that patient. It must provide enough information to justify the treatment performed. The important information to include on the dental chart are: the patient signalment, chief complaint, dental anatomic chart to include previously performed dental work, current pathology, treatments performed, a table to record probing measurements for each tooth, a key for abbreviations used, additional exam findings, comments section, imaging (dental radiographs +/- CBCT) findings, recommended follow ups, and home care recommendations. A small sticker of a mouth does not allow for this level of detailed documentation.

After the pet is under anesthesia, obtain photographs before you begin the oral exam or cleaning. A complete oral exam begins with observation and palpation of the cervical and facial region looking for asymmetries, swellings, draining tracts, painful areas, and mandibular lymph node enlargement. Check all surfaces of the teeth and note calculus and plaque indices, and document missing teeth and supernumerary teeth. Examine the non-dental oral tissues including the buccal mucosa, tongue, hard and soft palate, and tonsils for any abnormalities including granulomas, chewing lesions, lacerations, ulcerations, foreign bodies, or oral masses. Document the occlusion of individual teeth including crowded or rotated teeth. Class 2 and 3 malocclusions, crossbites, and asymmetries are best noted prior to intubation. Note the severity of gingivitis. Probe every single tooth. Walk the probe around the entire tooth and measure pocket depth, gingival enlargement, bleeding, gingival recession, furcation exposure and tooth mobility. 

A periodontal probe is essential for proper assessment of periodontium. There are different types of periodontal probes, so be sure you know the type you are using. The normal sulcus is between the tooth and free gingiva and the normal sulcus depth in a dog is less than 3 mm and less than 0,5 mm in a cat. The periodontal probe is walked around every single tooth at 4-8 sites. One must not use too much pressure and accidently create a pocket. Use gentle pressure.

Periodontal disease (PD) is staged by severity. PD Stage 0 has no gingivitis. Stage 1 PD is only gingivitis. Gingivitis is inflammation of the gingiva, without attachment loss. Stage 2 PD is gingivitis with <25% attachment loss. Stage 3 PD is gingivitis with 25-50% attachment loss. Stage 4 PD is gingivitis with >50% attachment loss. Periodontal disease stages can be for the generalized stage or a focal stage. To properly stage periodontal disease, one must perform a comprehensive oral exam. The oral exam will determine if there is attachment loss, and intra oral dental radiographs are used to help determine the percentage of attachment loss that is present.

Normal gingiva is pink and/or pigmented based on breed or that patient. Signs of gingivitis or periodontal disease are red, swollen gingiva that bleeds easily. Increased probing depths can be caused by attachment loss, gingival enlargements, incompletely erupted teeth. Gingival enlargements and overgrowth can cause pseudo pockets. There isn’t attachment loss, but there is a probing depth. One must be able to determine true attachment loss by adding the probing depth and gingival recession and subtracting the probing depth and gingival enlargement. A furcation is the area between the roots of a multirooted tooth. Furcation exposure is documented F1-F3. Furcation 1 (F1) is when the periodontal probe goes less than halfway between the roots. Furcation 2 (F2) extend halfway or more but not all the way through. A furcation 3 (F3) extends all the way through the roots.

 Mobility is also measured and documented. Stage 0 mobility (M0) is normal mobility of the teeth. The measurement can be up to 0.2mm. Stage 1 mobility (M1) measures from 0.2mm to 0.5mm. Stage 2 mobility (M2) measures 0.5mm to 1.0mm. Stage 3 mobility (M3) measures greater than 1.0mm. Rinse the oral cavity with 0.12% chlorhexidine solution. This reduces the number of bacteria that both the staff and patient are exposed to during the procedure. You can leave it on for a few minutes, or even brush the teeth with the solution before starting. A pointed tip explorer is used to identify tooth resorption, carious lesions, pulp or dentin exposure, and subgingival calculus. The explorer is placed on the tooth and not used to probe down into the sulcus as damage may occur.

Periodontal Cleaning
After the complete oral exam is completed, the dental cleaning is performed. Remove supragingival plaque and calculus. This is most important to the owner because it is what they see, however it is the least important to the patient. Use the powered (ultrasonic, magneto restrictive, or piezo) scaler to begin with. Do not spend more than ten seconds on a tooth at a time, and be sure you are using enough water to cool and irrigate the tooth as you work. Remove subgingival plaque and calculus with a curette or perio tip. This is the least visible to the owner but the most important to the patient. Plaque bacteria is the cause of periodontal disease, not calculus. The plaque must be removed from any subgingival space. Plaque is a biofilm that contains bacteria. Plaque is the filmy, soft deposit on our teeth that can be removed by brushing. Plaque then mineralizes to form calculus, which is also referred to as tartar. The minerals come from saliva. The hard, rough calculus increases the surface area for more plaque to stick to.

The biproducts of the plaque bacteria are toxic to the gingival tissues. They can break down collagen along with the hosts immune response and bone, eventually leading to attachment loss and destruction of the periodontium. Contributing factors to periodontal disease are malocclusions including crowded and rotated teeth, calculus, restorations, orthodontics, genetics, xerostomia, gingival enlargements, and systemic health. Always check your work. Use the air water syringe to rinse the mouth of calculus and blood, as well as drying the teeth when you are finished. Look for the chalky white residue that remains on the teeth. That is the calculus that has been missed. Remove what is left with a hand scaler and/or curette. Polish the teeth using fine or flour grade paste above and below the gum line. Flare the polishing cup under the gingival sulcus. Use a light touch and spend five to ten seconds or less per tooth. Polishing smooths the tooth surface and removes irregularities created by scaling. This decreases the surface area for plaque bacteria to stick to. Once all the calculus and plaque have been removed and teeth polished, rinse the tooth surface and sulcus to remove debris and paste. At this point, fluoride may be applied, which is an ingredient used to decrease tooth sensitivity. However, you should not use this in renal patients, as fluoride is excreted through the kidneys and our patients cannot spit it out.

Obtain full mouth radiographs! Radiographs are necessary and are part of comprehensive oral exam. We can see the crown and probe to determine periodontal pockets, but we cannot see what is below the gumline. Radiographs tell us if a tooth can be repaired or if it needs to be removed. This is an important diagnostic tool. Most of the pathology is below the gum line, and 80% of the dental anatomy is not visible. Radiographs must be obtained post extractions as well, to determine the entire tooth is removed and no fragments are left behind. A treatment plan should be customized for each tooth in every patient based on the complete oral exam, probing, and intraoral radiographs. A veterinarian must perform surgery, extractions, and advanced dental procedures. Take post procedure photographs of both sides, but be sure to cover the endotracheal tube with the tongue so it does not look too scary to the owner in the picture. 

Discharge instructions
Personalize the instructions based on the individual’s condition. Include feeding instructions, medications, and recheck dates. Have the directions and instructions for medications to go home in writing for the owner. It should include when the owner should start the medications, how often to give them, how many to give, what the medication is for, and for how many days. If oral surgery was performed, the pet needs to be rechecked within 7-14 days post operatively to make sure all sites are healed. They should also come back in 3, 6, 9 or 12 months for an oral exam. This is decided by not only the extent of periodontal disease present, but also the breed of your patient. Toy breeds are more predisposed to periodontal disease than large or giant breed dogs.

Discuss this with the owner. Put reminders in the computer to generate a reminder for future appointments. Discuss home care with the owner when they bring the pet back for the follow up exam. They are usually overwhelmed at the time of surgery and may not understand the conversation. Send a packet home with samples of all the products you carry that may be appropriate for that patient. Explain what they are and how they work. Now that the teeth are nice and clean, we need to keep them that way. Bacteria are already multiplying as they are walking out the door. Educate the client on the importance of home care to help protect their investment. Proper dentistry takes a team, but it can be achieved so we can improve the lives of pets, one tooth at a time.