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- Skull 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 borzois, standard poodles, Examination of the tion. A systematic approach using a dental and whippets, 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. 72 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com FREE Oral Examination of Cats and Dogs CE 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. CompendiumVet.com | February 2009 | Compendium: Continuing Education for Veterinarians® 75 FREE CE Oral Examination of Cats and Dogs 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 anatomy. 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