3 CE CREDITS CE Article 1

Oral Examination of Cats and Dogs

❯❯ Dale Kressin, DVM, DAVCD he oral examination is an integral part Cephalic Index Animal Dental Center— of every general physical examina- shape and size influence the incidence Milwaukee and Oshkosh tion for companion animals. Lesions of certain dental conditions.8 Understanding Glendale, Wisconsin T in the oral cavity may be clinical mani- skull classifications is important because festations of metabolic disease.1–4 Similarly, anatomic variations play a significant role the general physical examination may pro- in the extraoral and intraoral appearance vide important clues to intraoral disease and in dental occlusal relationships.9 processes.5 A general physical examina- The cephalic index categorizes dog and tion is also fundamental to choosing the cat breeds based on skull shape and size.8,10 optimal anesthesia protocol necessary to A relatively wide, short skull character- perform a comprehensive oral examina- izes brachycephalic breeds, such as bull- tion.6 In essence, the two examination dogs, shih tzus, Himalayans, and Persians. At a Glance components complement each other. Mesocephalic breeds, such as Alaskan mal- A comprehensive oral examination amutes, German shepherds, and Labrador Examination of the includes a nonsedated patient evaluation retrievers, have muzzles of intermediate Awake Patient of the head, neck, and oral cavity and a width and length. Dolichocephalic breeds, Page 72 sedated or anesthetized intraoral evalua- represented by , standard , Examination of the tion. A systematic approach using a dental and , have relatively long, nar- Anesthetized Patient chart with an anatomic checklist is most row muzzles. Page 77 efficient. Abnormal or suspicious findings Tooth Identification are recorded on the dental chart using Brachycephalic Breeds Systems for Use objective indices. This practice helps avoid Brachycephalic breeds with a complete in Dogs and Cats missing important details and allows for permanent dentition often have dental Page 79 comparison of findings between periodic crowding with tooth rotation and a rela- examinations.7 tively high incidence of periodontal dis- ease.9 Dental crowding and tooth rotation Examination of the Awake Patient often result in abnormal dental eruption. The Extraoral Examination Teeth may partially erupt or fail to erupt Facial Symmetry and Related Observations and remain embedded in subgingival tis- The extraoral examination begins with sue. The first premolars are commonly a careful evaluation of facial symmetry affected, and the lower first premolars are (Figure 1). Palpation of the face may iden- tify firm or fluctuant masses. Palpation of FIGURE 1 lymphatic and salivary tissue may reveal abnormalities related to intraoral disease. WEB Alopecia; draining tracts; discharge; scar- EXCLUSIVE ring; malodor from the ears, nose, mouth, or skin; and any other external findings are noted on the dental chart or anatomic A downloadable anatomic checklist. Opening and closing the mouth checklist and sample may reveal popping and clicking sounds or canine and feline dental crepitus within the temporomandibular joint. charts are available at Asymmetric facial swelling.a CompendiumVet.com. Palpating the left and right mandibles may reveal fractures or symphyseal instability. aAll images are courtesy of Dale Kressin, DVM, DAVCD.

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FIGURE 2 FIGURE 3

Missing first premolar tooth. Oral cyst at the location of the first premolar. frequently missing bilaterally (Figure 2). Dental Mesocephalic Breeds radiographs are essential when evaluating ani- Dental crowding and periodontal disease are mals with missing teeth to rule out embedded less common in mesocephalic breeds. The mes- teeth, which may result in the formation of ocephalic facial profile is intermediate between oral cysts 11–13 (Figure 3). These cysts are often the brachycephalic and dolichocephalic pro- locally destructive and may ultimately lead to files. Mesocephalic breeds have an increased tooth loss, jaw fracture, or other complications. incidence of missing premolars, especially the Brachycephalic breeds also exhibit anatomic first and fourth premolars. To confirm that variations associated with chronic obstructive missing teeth are not simply unerupted, dental respiratory syndrome (CORS).14 These varia- radiographs should always be obtained when tions include hyperplasia and elongation of teeth appear to be missing. Unerupted teeth QuickNotes the soft palate, eversion of the lateral saccules, can result in dentigerous cysts. An oral examina- stenotic nares, tracheal hypoplasia, and laryn- tion should be part 15 geal collapse. Dolichocephalic Breeds of every thorough Evaluation for CORS should be performed Dolichocephalic breeds may exhibit cau- physical examina- before intubation and without tongue retrac- dal (posterior) crossbite, a malocclusion in tion. The soft palate should not extend caudal which the upper fourth premolars (the car- tion. Veterinarians to the tip of the epiglottis. Everted laryngeal nassial teeth) are positioned lingual to the must be familiar saccules appear as off-white mushroom- lower first molars rather than the normal with normal anat- shaped structures rostral to (in front of) the buccal orientation.10 This condition is par- omy and variations vocal cords. Laryngeal collapse is identified ticularly common in collies.19 It may result in between breeds to as medial tipping of the corniculate processes less effective “shearing” activity of the car- be able to identify and flattening of the cuneiform process of nassial teeth, leading to increased accumula- potential problems. the arytenoid cartilage. Images and further tion of plaque and calculus20 and, ultimately, descriptions of these structures are published periodontal disease. elsewhere.16 Young to middle-aged dolichocephalic ani- Veterinarians should be prepared for anes- mals may be at increased risk of developing thetic complications when working with fungal (Aspergillus fumigatus) infections of brachycephalic patients. Tracheal intubation the nasal passages compared with animals may be difficult because of tracheal hypopla- with other skull shapes.21 These animals ini- sia, and partial airway obstruction may com- tially present with a unilateral hemorrhagic plicate anesthesia recovery. Brachycephalic and mucopurulent nasal discharge that often patients should remain intubated as long becomes bilateral with disease progression. as possible and should be monitored con- Depigmentation of the nasal planum may tinuously after extubation to ensure normal occur. Manipulation of the nose is often pain- breathing.17 Brachycephalic feline breeds seem ful for these animals. Rhinoscopy, computed to be at increased risk for developing nasal tomography, and fungal cultures help estab- aspergillosis–penicilliosis.18 lish the diagnosis.

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FIGURE 4 Feline oral examination.

A B C

D E F

(A) Secure the head at the zygomatic arch, holding gently but firmly. B( ) Pet the cat’s chin gently to provide reassurance. (C) Open the mouth. (D and E) Use a cotton-tipped applicator to protect fingers from injury while obtaining a clear view. F( ) View of hard palate. Note the rugae (folds).

The Intraoral Examination gently secures the dog’s head and body while I The initial examination of both cats and dogs perform a closed-mouth examination from the is attempted with the mouth closed. To avoid front and both sides (Figure 5). The assistant injury to the patient and the examiner, it is then holds the mandible and maxilla in the helpful to have an assistant restrain the patient. premolar region to slowly and gently encour- The upper and lower lips are viewed and then age the dog to open its mouth. Allowing a QuickNotes gently separated to get views of the dentition, dog to open and close its own mouth helps oral mucosa, and dental occlusion. Front and with the awake oral examination. Forcing the Using patience side views of the oral cavity may allow obser- mouth open and holding it open results in and a gentle tech- vation of some surfaces of all of the teeth. I use patient resistance and difficulty for the exam- nique during the a 6-inch cotton-tipped applicator to help avoid iner; therefore, in my practice, we do not force oral examination personal injury while viewing oral . the mouth into an open position. Caution and allows optimal For cats, I prefer to sit or stand directly patience are strongly advised. Some fearful or visualization of oral behind the patient. To reduce stress and help aggressive animals require chemical restraint. comfort the cat, I speak softly and gently pet The gingiva, alveolar mucosa, cheek mucosa, structures and iden- the cat’s head and neck before palpating the lips, palate, incisive papilla, tongue, and floor tification of poten- neck and mandibular lymph nodes. I then tilt of the mouth are briefly viewed during the tial problems while the cat’s head back to point the nose toward the awake patient oral examination. Any discharge, avoiding injury to ceiling. This relaxes the lower jaw, which I gen- discoloration, draining tract, fistula, foreign the evaluator and tly pull down with a finger to open the mouth. I body, inflammation, mass, swelling, fracture, patient. can then view the oral cavity (Figure 4). or ulceration should be noted on the dental For dogs, I approach from the side, using chart. These abnormalities can be investigated gentle techniques to relax the patient. Many further after the animal is sedated or under dogs respond favorably to their name spoken anesthesia. in a slow, calm, soft voice. Repeated gentle The awake patient intraoral examination petting can also be reassuring. An assistant can be very revealing. All observed abnormali-

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FIGURE 5 Canine oral examination.

A B C

(A) Front view of gingiva. Note the mucogingival line separating the attached gingiva from the free alveolar mucosa. (B) Right-side oral mucosa. (C) Left-side oral mucosa. ties should be discussed with clients to help Equipment and Instrumentation convey the importance of performing a com- A comprehensive intraoral examination requires prehensive intraoral examination under gen- an adequate light source with magnification, a eral anesthesia. Diagnostics help to establish Finoff transilluminator or bright penlight, a den- an accurate diagnosis and carry out an opti- tal radiography machine, periodontal explorer mal treatment plan. probes, appropriate anesthesia equipment and supplies, atraumatic tissue retractors, and Examination of the Anesthetized Patient mouth gags. An adequately sized, uncluttered Anesthesia allows a meticulous, systematic work area is preferred to avoid distraction of approach to the intraoral examination. The larynx, the evaluator. oropharynx, tonsils, soft palate (Figure 6), hard palate, incisive papilla, gingiva, alveolar mucosa, Evaluation of the Occlusion buccal mucosa, tongue, floor of the mouth, and While performing the intraoral examination, salivary structures can all be visualized. After the examiner must answer the following ques- thorough scaling (above and below the gum tions to determine whether findings are nor- line) and polishing, the teeth, along with the mal or further evaluations are indicated. periodontal tissue, are evaluated visually, by tactile probing, by dental radiography, and by Is the bite right? The patient is first evalu- QuickNotes transillumination. The number, color, shape, ated for a normal occlusion (“scissors bite”) size, and condition of the teeth are assessed. with the mouth closed.22–25 In a normal canine The use of a system- The use of objective indices allows for consis- occlusion, the upper incisors overlap the lower atic approach and tent dental evaluations. incisors, with the coronal tips of the lower objective indices incisors resting on the cingulum of the upper FIGURE 6 enables a meaning- incisors. The lower canines should fit into the ful evaluation of diastema (space) between the upper canines dental, periodontal, and the adjacent third incisors without contact oral, and extraoral between any teeth. The upper and lower pre- molars should interdigitate, with the lower pre- tissue. All abnormal molars positioned rostral to the upper opposing findings should teeth. The coronal tips of the lower premolars be recorded on a are positioned in the interdental spaces of the dental chart or ana- upper premolars, and these opposing teeth tomic checklist. do not come into contact. The lower fourth premolar cusp tip is positioned between the upper third and fourth premolars. The preced- ing third, second, and first premolars have the Soft palate defect. Note the purulent discharge. same relationship bilaterally. The crown cusps

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of the lower premolars are positioned lingual of the upper fourth and third premolars. The to the opposing premolars of the upper dental teeth in the upper and lower arches do not arches. The mesial crown cusp of the upper come into coronal contact. The lower third and fourth premolar is positioned lateral to the fourth premolars are oriented lingual to the interdental space of the lower first molar and premolars of the upper dental arch. The upper the adjacent fourth premolar. fourth premolar in cats is positioned similar to QuickNotes Adult cats have occlusal relationships simi- that in dogs. The mesial aspect of the crown lar to those in dogs; however, they have fewer cusp of the upper fourth premolar is posi- Dental radiographs teeth. When the normal adult feline occlu- tioned lateral to the interdental space of the and periodontal sion is viewed from the front with the mouth lower molar and the adjacent fourth premolar probing are funda- closed, the upper incisors slightly overlap the tooth. The orientation of the upper fourth pre- mental diagnostic lower incisors or have direct coronal contact. molars is clinically significant. Cats often pres- tests used in the The lower canines fit into the narrow diastema ent with mandibular mucosal “oral masses” or oral examination. between the upper canines and the adjacent “lesions” as a result of occlusal trauma. Ancillary tests may third incisors. When the occlusion is viewed from the side with the mouth closed, the rela- Do the teeth occlude functionally and atrau­ help establish a tionship of the upper and lower premolars is matically? Traumatic malocclusions, such as definitive diagno- similar to that in dogs; however, cats normally tooth-on-tooth or tooth-on-soft tissue contact,9 sis for treatment have two fewer premolars and molars on each can be very painful for companion animals. planning. mandible and one less premolar and one less Traumatic malocclusion is particularly common molar on each upper dental arch. (Sample when there is a discrepancy in jaw length or a feline and canine dental charts are available variation in tooth position. at CompendiumVet.com.) The lower premolar teeth are oriented rostral to the upper premolar Is the number of teeth present normal? teeth, and the crown cusp of the lower fourth Missing or supernumerary teeth must be rec- premolar is positioned in the interdental space ognized and charted.9 Dental radiographs are needed to establish the correct diagnosis.

table 1 Eruption Times for Deciduous Do the teeth appear normal? Abnormal tooth and Permanent Teeth in Cats and Dogs22 structure (enamel defects or fractures), shape (malformations), or discoloration may be iden- Eruption of Deciduous Teeth Eruption of Permanent Teeth tified. Fractured and worn teeth may be pres- (weeks of age) (months of age) ent. All of these abnormal findings should be charted. Dogs Number of Teeth Incisors 3–4 3–5 Fundamental knowledge of the normal decidu- ous, permanent, and mixed (deciduous and Canines 3 4–6 permanent) dentition is necessary to perform Premolars 4–12 4–6 the oral examination. A basic understanding of deciduous and permanent tooth eruption Molars None 5–7 (Table 1) and the normal number of teeth (Box 1) is important to be able to differentiate Cats between normal and abnormal development.22 I prefer to start the dental examination with Incisors 2–3 3–4 the patient in left lateral recumbency and eval- uate the right upper and lower dental arches Canines 3–4 4–5 for the full complement of teeth. There should be one canine and three incisors on each side Premolars 3–6 4–6 of each arch. On the upper arch, the right upper fourth premolar is the largest tooth. In Molars None 4–5 adult dogs, the third, second, and first premo- lars are found in successive positions rostral to

78 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com FREE Oral Examination of Cats and Dogs CE the fourth premolar, and the first and second Box 1 molars are immediately caudal to the fourth Tooth Identification Systems premolar. Adult cats have three upper premo- 5,8 lars and one upper molar. On the lower arch, for Use in Dogs and Cats the first molar is the largest tooth. In adult dogs, the four lower premolars are rostral to The Anatomic Tooth Identification System the first molar, and the second and third lower These dental formulas are used to evaluate for the full complement of molars are caudal to it. Adult cats have two teeth. Each formula denotes the teeth on one side. The upper number lower premolars and one lower molar. I then represents the upper dental arch; the lower number, the lower arch. evaluate the left side and compare it with the The total number of teeth is determined by multiplying the formula right side. Missing teeth are circled on the den- total by two because the left and right sides are symmetric. tal chart, and supernumerary teeth are drawn Dogs 3 1 3 0 on the chart in the locations where they are Deciduous dentition: i 3 c 1 p 3 m 0 = 28 3 1 4 2 observed. Permanent dentition: I 3 C 1 P 4 M 3 = 42 Cats 3 1 3 0 Plaque, Calculus, and Periodontal Disease Deciduous dentition: i 3 c 1 p 2 m 0 = 26 3 1 3 1 Accumulations of plaque and calculus, the Permanent dentition: I 3 C 1 P 2 M 1 = 30 presence of gingival inflammation, furcation c = deciduous canine, C = permanent canine, i = deciduous exposure, and tooth mobility are noted on the incisor, I = permanent incisor, m = deciduous molar, M = dental chart. A furcation is the space between permanent molar, p = deciduous premolar, P = permanent two roots of the same tooth. Periodontal premolar disease results in bone loss, which exposes a the furcation. Furcation exposure and tooth The Modified Triadan System mobility are important findings that suggest I use the modified Triadan system for medical records. For case advanced periodontal disease or other pathol- reports sent to referring veterinarians, I use both the anatomic and ogy. Tooth mobility can also be related to root modified Triadan systems to avoid misunderstanding. The modified fracture, metabolic disease, or neoplasia.26 Triadan system can be used for all species. The system for veterinary use is based on three-digit numbers because the upper dental arches Periodontal probing and dental radiographs of dogs normally have 10 teeth and the lower arches have 11 teeth. are needed to evaluate the extent of periodon- In this system, the dental arches are numbered from the right up- tal disease. To make evaluations simple and per (100), to the left upper (200), to the left lower (300), and finally consistent between periodic oral examinations to the right lower (400). Individual teeth are then numbered succes- and between evaluators, calculus, plaque, and sively from the most rostral to the most caudal tooth. For example, gingival indices (Boxes 2, 3, and 4) are used. the incisor adjacent to the facial midline of the upper right dental arch Tooth furcation and mobility indices (Boxes 5 is numbered 101, while the right lower first incisor adjacent to the and 6) with periodontal disease staging (Box mandibular symphysis is numbered 401. The adjacent incisors on the 7) may also be recorded. right side are numbered 102 and 103 (upper arch) and 402 and 403 I use a three-point index or stage for each (lower arch), respectively. All cuspids or canine teeth are numbered assessment (four stages for periodontal disease) 04, all fourth premolar teeth are numbered 08, and the first molars are and chart only abnormal findings. For plaque numbered 09. and calculus, stage 1 indicates a relatively small In dogs, the four right lower premolars from rostral to caudal are amount, with 2 and 3 indicating moderate and numbered 405, 406, 407, and 408. The right lower molars from ros- heavy accumulations, respectively. Gingival tral to caudal are numbered 409, 410, and 411, respectively. In cats, stages of 1, 2, and 3 indicate minimal, moderate, gaps are left in the numbering sequence for the teeth that are normally and significant inflammation. The furcation, gin- absent. For example, the right upper first premolar observed in normal gival, mobility, and periodontal disease stages feline dentition is numbered 106 because 105 is absent. From rostral are recorded next to each tooth, whereas the to caudal on the right upper dental arch, the adjacent teeth are desig- plaque and calculus indices are general assess- nated 107, 108 (the third and fourth premolars, respectively), and 109 ments of the full dentition. (the only molar tooth). On the right lower dental arch, the first encoun- It is important to recognize areas of the tered premolar tooth is numbered 407 (405 and 406 are absent), the dentition that have particularly heavy accumu- adjacent premolar (the fourth premolar) is labeled 408, and the most lations of plaque and calculus compared with caudal mandibular tooth is labeled 409 (the only molar tooth). the contralateral side, as these may indicate aSee the charts at CompendiumVet.com for an example of the modified inadequate occlusal function or lack of chew- Triadan numbering system in use.

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ing due to oral pain or other causes. Regional The periodontal probe is used for a three- disparity between objective indices necessi- dimensional assessment of the periodontium.28 tates careful observation, tactile assessments, It is placed at six imaginary points of the tooth.29 and full-mouth dental radiographs. I prefer to probe the buccal surface from the Periodontal and explorer probes are used mesial aspect (front) to the middle point and for tactile assessments of teeth and periodon- then the distal aspect (back) of the tooth. I tal tissue assessment.27 Explorer probes are then position the probe at the distal aspect of made with various working ends. A number 17 the lingual or palatal surface and continue to explorer probe is useful for subtle evaluation of the middle and mesial points of each tooth. enamel, dentin, and cementum or evidence of With experience, periodontal probing of the pulp exposure.7 The shepherd’s hook explorer four dental arches takes approximately 60 sec- probe is useful for the evaluation of dental onds with the help of a dental assistant record- integrity and evidence of pulp exposure. ing abnormal findings on the dental chart.30

Box 2 Tooth Color Modified Ramfjord Calculus Index44 Tooth color depends on dental care, diet, age, and other factors.5 Professional and home den- tal care reduces accumulations of plaque and CI-0: No calculus; not charted calculus that affect tooth color. Dietary factors CI-1: Minimal supragingival calculus deposition can influence accumulations of plaque and CI-2: Moderate subgingival and supragingival calculus deposition calculus as well as introduce biochemicals that CI-3: Heavy calculus deposits on crown and subgingivally may affect tooth color. I often see patients with tooth surfaces that are discolored red or black, Box 3 presumably from minerals in local water sup- Plaque Index44 plies (Figure 7). Young cats and dogs have teeth with wide PI-0: No plaque; not charted pulp chambers and thin dentin walls com- PI-1: Minimal gray-tan plaque deposits pared with those of older animals. As animals PI-2: Moderately dense gray-tan plaque deposits age, the dentin walls develop (or enlarge), PI-3: Heavy plaque deposition exudes from gingival sulcus resulting in greater tooth density with a yellow, tan, or off-white appearance. Elderly patients may develop sclerotic dentin and pulp cham- Box 4 ber shrinkage, which may result in a glassy or Gingival Index44 transparent appearance of the teeth. The outer enamel layer of the tooth is GI-0: Normal gingival shape and color; not charted nonliving and remains approximately the GI-1: Mild gingival inflammation, swelling, slight red color same thickness throughout the animal’s life. GI-2: Moderate gingival inflammation, swelling, red with bleeding However, nutrition, general health, and anti- GI-3: Severe gingival inflammation, swelling, bright red with bleeding microbial therapy may affect enamel forma- tion and, ultimately, tooth color.31 For example, Box 5 FIGURE 7 Furcation Indexa

F-1: Furcation exposure; probe extends less than halfway under the crown in any direction of a multirooted tooth with attachment loss F-2: Moderate furcation exposure; probe extends more than halfway under the crown of a multirooted tooth with attachment loss but not all the way through F-3: Extensive furcation exposure; probe passes from one side all the way through (through-and-through exposure)

aAmerican Academy of Periodontology. Clinical Periodontology. 2nd ed. New York: Thieme Medical Publishers; 1989. Black mineral deposits within calculus contrib- ute to tooth discoloration.

80 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com FREE Oral Examination of Cats and Dogs CE tetracycline administration during tooth devel- tooth color. The pulp responds to trauma with opment may affect the formation of hydroxy- inflammation as an attempt to repair itself; apatite of permanent teeth. Changes related however, pulp necrosis with tooth discolor- to enamel abrasion and attrition also affect ation frequently occurs. tooth color.22 Infectious disease, malnutrition, Teeth that are purple, pink, tan, brown, or trauma may disrupt normal enamelogenesis black, or just off-white should be evaluated and result in enamel defects31 (Figure 8). These further. Discolored teeth may have reversible defects can result in irregular dentin formation or irreversible pulpitis (Figure 9) or may be and plaque and calculus retention, which con- nonvital.33 Discolored teeth should be evalu- tribute to tooth discoloration. ated tactilely with an explorer probe for dentin Extraoral or intraoral occlusal trauma may or pulp exposure and with dental radiographs result in tooth wear, fractures, or pulpitis. for endodontic pathology.34 Dentin responds to chronic trauma by produc- Transillumination of discolored teeth may ing reparative (tertiary) dentin.32 Reparative help determine tooth vitality,22 particularly in dentin increases the tooth density and affects younger patients. I use a Finoff transillumina- tor to direct light through the potentially non- FIGURE 8 vital tooth. A pink glow indicates illumination of blood flowing through the pulp and is con- sistent with tooth vitality. A tooth that appears relatively dark and does not have a pink glow when compared with adjacent and contralat- eral teeth is likely nonvital. Transillumination is an inexact procedure in older patients because of the variability in tooth density.

Tooth Shape and Size Enamel defect. Knowledge of the correct shape and size of teeth is necessary to recognize anomalous FIGURE 9 teeth,35 such as peg teeth, which are small and have a single cusp. , models, photographs,

Box 6 Mobility Indexa

M-0: Normal physiologic movement (<0.2 mm), not charted M-1: Slight tooth mobility in any direction other than axial (0.2–0.5 mm) M-2: Moderate tooth mobility in any direction other than axial (0.5 to 1 mm) M-3: Severe tooth mobility in any direction other than axial (>1 mm) Pulpitis; view of lingual aspect of lower first molar. aAmerican Veterinary Dental College Nomenclature Committee. FIGURE 10 Box 7 Periodontal Disease Index44

Periodontal disease is staged based on the degree of periodontal destruction. Dental radiographs with periodontal probing are the fundamental diagnostic tests used. PD-1: Stage 1 periodontal disease; no attachment loss PD-2: Stage 2 periodontal disease; 0–25% attachment loss A periodontal probe penetrates a defect in this PD-3: Stage 3 periodontal disease; 25%–50% attachment loss malformed canine tooth. Note the purulent discharge PD-4: Stage 4 periodontal disease; >50% attachment loss and the hair embedded within the dental defect.

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and dental charts are commercially available Defects and Trauma for comparison with a patient’s dentition to Coronal defects may involve only the enamel, help veterinarians recognize anomalous teeth. the enamel and dentin (Figure 12), “near pulp Anomalous teeth may be an incidental find- exposure,” or direct pulp exposure (Figure 13). ing, a functional problem, or a contributing Teeth with coronal defects often have rough factor in the development of periodontal dis- surfaces with accumulations of plaque and ease (Figure 10). All anomalous teeth should calculus. be probed for enamel and periodontal defects The carnassial teeth are frequently chipped as well as radiographed for periodontal and or fractured in dogs that are allowed to chew endodontic pathology (Figure 11). hard objects. Caged animals with separation

FIGURE 11 FIGURE 12 FIGURE 13

Anomalous lower molar. The molar cusps Fracture; dentin exposed. Pulp exposed. are short and blunted. Note the enamel defect adjacent to the gingival margin.

FIGURE 14 FIGURE 15 FIGURE 16

Dental abrasion due to cage chewer syn- Severe dental attrition of a lower sec- Severe slab fracture of an upper fourth drome. Notice the severely abraded distal ond molar from tooth-on-tooth wear. premolar. This is a crown-root fracture that aspect of the canine tooth caused by chew- extends below the gingival margin. ing on the cage door. Crown therapy can help protect these teeth from dental fracture.

FIGURE 17 FIGURE 18 FIGURE 19

Feline tooth resorption. Carious lesion in an upper first molar. Draining fistula apical to (above) the mucogingival line.

82 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com FREE Oral Examination of Cats and Dogs CE anxiety frequently incur defects or fractures on Soft Tissue Evaluation the distal surfaces of incisors, canines, and pre- I prefer to evaluate the soft tissue after the molars while trying to escape from their cages. teeth have been evaluated. I assess all four These defects are particularly common in dogs, dental arches for normal gingival color and and their presence has been called cage chewer anatomy. My initial focus is on the attached syndrome (Figure 14). Dogs that habitually gingiva. There should be a minimum of 2 to carry tennis balls develop severe dental abrasion. 3 mm of attached pink gingiva around every Dental attrition is abnormal coronal wear due to tooth.42 Gingival defects or recession may excessive mastication or chewing (Figure 15). result in less than 2 mm of attached gingiva. Slab fracture of a carnassial tooth (Figure 16) Gingival discoloration, inflammation, and frequently results in suborbital swelling. How­ edema may also be evident. Because the ever, dental radiography should be performed attached gingiva protects the teeth and other before extracting the fractured tooth to ensure periodontal structures, its loss creates a risk accurate diagnosis and treatment of the tooth for periodontal disease progression, endodon- or teeth causing the swelling.36 Tooth root tic disease development, and the eventual loss abscess of the upper third premolar or upper of adjacent teeth. first molar, foreign body penetration, and The mucogingival line is a clinically important infectious or neoplastic diseases can also region. If discharge or fistulas are identified at cause swelling and must be ruled out via den- or apical to the mucogingival line (Figure 19), tal radiography. Lingual fractures of the lower endodontic disease of the adjacent tooth is first molars are also common but are often likely.43 If discharge or fistulas are identified missed during routine oral examination. coronal to the mucogingival line, periodontal Tooth resorption in cats (formerly called disease is suspected.43 Dental radiographs are neck lesions, resorptive lesions, erosive lesions, necessary when these fistulas are identified. or feline odontoclastic resorptive lesions) is The buccal mucosa is carefully examined very common37,38 (Figure 17). Tooth resorp- for defects, enlargements, lacerations, masses, tion occasionally occurs in dogs. Identification and ulcerations. Chronic ulcerative paraden- of tooth resorption on oral examination is a tal stomatitis (CUPS) is a common problem in strong indication for dental radiography.39 An dogs.44 It is an immune-mediated response to animal with one visible lesion is likely to have plaque bacteria that has also been referred to more. as plaque intolerance.45 These animals present Dogs may have dental caries (cavities) with ulcerative lesions of the buccal mucosa (Figure 18). Dental caries may involve the and the tongue surfaces that come in contact crown or root but are most commonly found with the teeth (Figure 20). CUPS is similar to on the occlusive surfaces of the molars.40,41 feline stomatitis.

FIGURE 20 CUPS lesions.

A B

(A) Buccal ulceration. Ulceration typically occurs at locations where the mucosal tissues contact the teeth (and bacterial plaque). (B) Tongue ulceration. Note the hyperemic, ulcerated tongue margins. These lesions can be particularly painful.

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Conclusion deposition on teeth. Gingival, furcation, An awake patient oral examination is an mobility, and periodontal disease staging integral part of every physical examination. is useful in assessing periodontal health. Familiarity with normal anatomy and breed These indices are charted only when prob- variations is essential for recognizing potential lems are identified. Dental charts provide problems. Abnormalities identified during the excellent documentation of the oral exami- initial awake patient examination need to be nation for the medical record. Dental radio- investigated further. The comprehensive oral graphs, periodontal and dental probing, and examination under anesthesia is a detailed transillumination of teeth are fundamentally and systematic evaluation of dental, periodon- important diagnostic tests used in the com- tal, and oral cavity structures. The use of a prehensive oral examination. dental chart with an anatomic checklist helps Information from the comprehensive oral the evaluator avoid missing problems and examination can be used in dental consulta- allows comparison between examinations. tions with clients for effective communication Plaque and calculus indices are quanti- about necessary treatment plans for their com- tative assessments of plaque and calculus panion animals.

References 1. Chuang S, Sung JM, Kuo SC, et al. Oral and dental manifestations in 19. Basics of orthodontics. In: Wiggs RB, Lobprise HL. Veterinary diabetic and nondiabetic uremic patients receiving hemodialysis. Oral Dentistry Principles and Practice. Philadelphia: Lippincott-Raven; Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99(6):689- 1997:464-479. 695. 20. Johnston N. Crunch time: approaches to bite abnormalities and 2. Van Nice E. Management of multiple dental infections in a dog malocclusions. Vet Times 2006 Dec 18:10-13. with diabetes mellitus. J Vet Dent 2006;23(1):18-25. 21. Cohn LA. Chronic nasal discharge in dogs. Proc Atl Coast Vet 3. Mealey BL. Diabetes and periodontal disease: two sides of a Conf 2006. coin. Compend Contin Educ Dent 2000;21:943-946. 22. Oral anatomy and physiology. In: Wiggs RB, Lobprise HB. Com- 4. Jordan RCK. Diagnosis of periodontal manifestations of sys- mon Dental Procedures. Lakewood, CO: AAHA Press; 2000:8-9. temic disease. Periodontology 2000;23:217-228. 23. Surgeon TW. Fundamentals of small animal orthodontics. Vet 5. Oral anatomy and diagnosis. In: Wiggs RB, Lobprise HB. Vet- Clin North Am Small Anim Pract 2005;35:869-871. erinary Dentistry Principles and Practice. Philadelphia: Lippincott- 24. Hobson P. Normal occlusion in the dog. J Vet Dent 2005;22:196- Raven; 1997:87-99. 198. 6. Muir WM. Considerations for general anesthesia. In: Thurmon 25. Kressin DJ. Veterinary orthodontics: some cases require brac- J, Tranquilli W, Benson G, eds. Lumb & Jones’ Veterinary Anesthe- es. DVM InFocus 2006 Sep:12-16. sia. 3rd ed. Baltimore: Williams & Wilkins; 1996:7-30. 26. Greenstein G, Polson A. Understanding tooth mobility. Com- 7. Dental records. In: Holmstrom SE, Frost P, Eisner ER. Veteri- pend Contin Educ Dent 1988;9:470. nary Dental Techniques. 2nd ed. Philadelphia: Saunders; 1998:4- 27. Wiggs RB, Lobprise HB. Dental equipment. In: Veterinary 21. Dentistry Principles and Practice. Philadelphia: Lippincott-Raven; 8. Gioso MA, Carvalho VG. Oral anatomy of the dog and cat in 1997:4-27. veterinary dentistry practice. Vet Clin North Am Small Anim Pract 28. Wiggs RB, Lobprise HB. Materials and equipment. In: Common 2005;35:763-780. Dental Procedures. Lakewood, CO: AAHA Press; 2000:162. 9. Hale FA. Juvenile veterinary dentistry. Vet Clin North Am Small 29. Harvey CE, Emily PP. Periodontal disease. In: Small Animal Anim Pract 2005;35:789-817. Dentistry. St. Louis: Mosby; 1993:100-103. 10. Oral anatomy and physiology. In: Wiggs RB, Lobprise HB. Vet- 30. Clinical examination. In: Tutt C. Small Animal Dentistry: A Man- erinary Dentistry Principles and Practice. Philadelphia: Lippincott- ual of Techniques. Ames, IA: Blackwell Publishing; 2006:42-44. Raven; 1997:77-79. 31. Miles AEW, Grigson C. Enamel hypoplasia. In: Colyer’s Varia- 11. Lobprise HL, Wiggs RB. Dentigerous cyst in a dog. J Vet Dent tions and Diseases of the Teeth of Animals. New York: Cambridge 1992;9(1):13-15. University Press; 1990:437-454. 12. Gioso MA, Carvalho VG. Maxillary dentigerous cyst in a cat. J 32. Andreasen JO. Response of oral tissues to trauma. In: Textbook Vet Dent 2003;20(1):28-30. and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. St Louis: 13. Colmerry B 3rd. The gold standard of veterinary oral health Mosby; 1994:77-132. care. Vet Clin North Am Small Anim Pract 2005;35:781-787. 33. Hale FA. Localized intrinsic staining of teeth due to pulpitis and 14. Wykes PM. Brachycephalic airway obstructive syndrome. Probl pulp necrosis in dogs. J Vet Dent 2001;18(1):14-20. Vet Med 1991;3(2):188-197. 34. Endodontic therapy. In: Tutt C. Small Animal Dentistry: A Man- 15. Riecks TW, Birchard SJ, Stephens JA. Surgical correction of ual of Techniques. Ames, IA: Blackwell Publishing; 2006:215. brachycephalic syndrome in dogs: 62 cases (1991–2004). JAVMA 35. Miles AEW, Grigson C. Order Carnivora. In: Colyer’s Variations 2007;230(9):1324-1328. and Diseases of the Teeth of Animals. New York: Cambridge Univer- 16. Done SH, Goody PC, Evans SA, Stickland NC. The Dog & Cat sity Press; 1990:62-90. Color Atlas of Veterinary Anatomy. Vol 3. Philadelphia: Mosby; 36. Hoffman SL, Kressin DJ, Verstraete FJM. Myths and miscon- 1996:2.44-2.45. ceptions in veterinary dentistry. JAVMA 2007;231(12):1-7. 17. Anesthetic considerations in patients with preexisting problems 37. Roux P, Berger M, Stoffel M, et al. Observations of the peri- or conditions. In: Paddelford RR. Manual of Small Animal Anesthe- odontal ligament and cementum in cats with dental resorptive le- sia. 2nd ed. Philadelphia: Saunders; 1999:315-316. sions. J Vet Dent 2005:22(2):74-85. 18. Whitney J, Broussard J, Stefanacci JD. Four cats with fungal 38. Ingham KE, Gorrel C, Blackburn J, Farnsworth W. Prevalence of rhinitis. J Feline Med Surg 2005;7(1):53-58. odontoclastic resorptive lesions in a population of clinically healthy

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cats. J Small Anim Pract 2001;42:439-443. with a maxillary canine tooth in a dog. J Vet Dent 2005;22(4):234- 39. Lommer MJ, Verstraete FJM. Prevalence of odontoclastic re- 242. sorptive lesions and periapical radiographic lucencies in cats: 265 43. Wiggs RB, Lobprise HB. Clinical oral pathology. In: Veterinary cases (1995-1998). JAVMA 2000;217:1866-1869. Dentistry Principles and Practice. Philadelphia: Lippincott-Raven; 40. Miles AEW, Grigson C. Caries of the teeth. In: Colyer’s Varia- 1997:114-119. tions and Diseases of the Teeth of Animals. New York: Cambridge 44. Periodontology. In: Wiggs RB, Lobprise HB. Veterinary Dentistry University Press; 1990:476-477. Principles and Practice. Philadelphia: Lippincott-Raven; 1997:196- 41. Restoration. In: Tutt C. Small Animal Dentistry: A Manual of 227. Techniques. Ames, IA: Blackwell Publishing; 2006:207-209. 45. Wiggs RB, Lobprise HL. Periodontal disease. In: Common Den- 42. Rawlinson JE, Reiter AM. Repair of a gingival cleft associated tal Procedures. Lakewood, CO: AAHA Press; 2000:45.

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1. Which patient characteristic is usu- b. Mixed dentition refers to patients hav- 8. Which statement regarding enamel ally best evaluated during the sedated ing deciduous and permanent teeth. defects is true? patient examination? c. Adult cats normally have only one molar a. Enamel defects are rarely of clinical a. cephalic index tooth in each dental arch. significance. b. anomalous teeth d. all of the above b. Enamel defects may involve only the c. facial symmetry enamel or both the enamel and the d. occlusion 5. Which breed is most likely dentin. to have CORS? c. Enamel defects are usually inherited 2. Which statement regarding the cephalic a. problems. index is true? b. d. Enamel defects are unlikely to be related a. Cephalic indices allow the veterinary c. to occlusal trauma. dentist to assess the patient for endo- d. dontic therapy. 9. Cage chewer syndrome refers to b. The cephalic index is a measurement of 6. Which statement regarding tooth color is ______resulting from the patient the coronal width and height of the right true? chewing metal cages. mandibular first molar tooth. a. Tooth color depends on dental care, diet, a. periodontal disease c. The cephalic index categorizes dog and age, and other factors. b. a pathologic condition associated cat breeds based on skull shape and size. b. Tooth discoloration is an indication for with toxicity d. The cephalic index applies to cat breeds teeth scaling. c. an enamel defect but not to dog breeds. c. Teeth normally change from yellow to d. a combination of three problems (an white at approximately 9 to 11 years of enamel defect, bacterial invasion of the 3. Which statement is false with regard to age. pulp, and endodontic and periodontal dental occlusion? d. Discolored teeth are common and rarely diseases) a. In a normal canine occlusion, the upper a reason for concern. incisors rest on the cingulum of the 10. Which statement is true? lower incisors. 7. Which statement regarding diagnostic a. Dolichocephalic dogs are affected b. In a normal canine occlusion, the upper tests is true? by periodontal disease more often and lower premolars interdigitate, with a. Dental radiographs are useful for endo- than brachycephalic breeds because the lower premolars positioned rostral dontic evaluation but not for periodontal they have a greater incidence of to the upper opposing teeth. evaluation. dental crowding. c. The patient can be evaluated for a nor- b. The periodontal probe is the only diag- b. A minimum width of 2 to 3 mm of mal occlusion with the mouth closed. nostic test for tooth resorption. attached gingiva is needed to protect d. Traumatic malocclusions with tooth-on- c. The periodontal probe is used for a the adjacent tooth. tooth or tooth-on-soft tissue contact three-dimensional assessment of the c. CUPS is not an immune-mediated can be painful for companion animals. periodontium. condition. d. Dental radiographs are rarely useful for d. all of the above 4. Which statement(s) regarding number of diagnosis of tooth resorption. teeth is/are true? a. If teeth appear to be missing, dental radiographs are indicated.

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