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Veterinary dental charting is essential – it documents the oral condition before treatment, identifies all pathology & serves as a record of all treatment performed.
Completing a Dental Chart is an important step in every dental procedure. It documents the oral condition before treatment, identifies all pathology found through both physical examination and radiographic assessment, and serves as a record of all treatment performed. In combination with patient history, examination findings, photographs and x-rays, the dental chart completes the patient’s record.
Dental Charting should be performed in the most efficient manner using a systematic approach – the Clinician performs the examination while the Veterinary Nurse/Technician completes the record. Let’s look at some simple steps to make Dental Charting more efficient and accurate for your team.
To ensure efficiency, remember that a Blank Dental Chart denotes a healthy patient – i.e. one that has no abnormalities. Only ‘abnormalities’ are recorded on the Chart, not anything ‘normal’ or healthy. This will save you time and keep your Dental Chart clear, with only pathology and treatment appearing. I have provided industry-standard abbreviations to use when recording on your dental chart – the abbreviations appear in brackets throughout this article.
Step 1: Conscious Patient Exam
Recording the condition of the oral cavity commences before induction. An assessment of these key areas:
Occlusion / Bite Assessment (MAL)
Malocclusions, particularly traumatic malocclusions, are assessed in the conscious patient. The mouth should be closed and assessed on both sides and from the front, looking for any tooth-on-tooth or tooth-on-soft-tissue contact. Record the Class of malocclusion and any traumatic contact. Refer to AVDC.org for resources on the four types of malocclusions.
Oropharynx Assessment
Prior to intubation, an assessment of the oropharynx should be carried out. It should also be noted that an examination of the oral mucosa, lips and cheeks, hard palate and the floor of the mouth is a necessary step in the anaesthetised patient’s oral examination.
Step 2: Use a Standard System
Consistency across the team improves efficiency and accuracy. The Chart is designed to be read from top to bottom – do the same with your assessment. Begin assessing each tooth from the maxillary first incisor (e.g. 101) to the molar (e.g. 110), working from the front of the mouth to the back. Then begin the mandibular examination by simply dropping down to the mandibular molar (e.g. 411) and working toward the first incisor (e.g. 401). This allows the nurse to follow along from the top of the chart to the bottom, creating less confusion and allowing you to both work efficiently and save time with your Charting. Teamwork makes the Dream-Work!
Assess each tooth in turn for:
Primary (deciduous), permanent (adult) or persistent deciduous tooth (DT/P)*
*Findings to be confirmed with diagnostic radiographic examination.
Step 3: Periodontal Examination
It is as simple as 1, 2, 3 – Mild, Moderate, or Severe. Using a standardised scoring system (indices) across the assessment of Calculus, Gingivitis, Furcation Exposure, and Mobility also helps with efficiency and accuracy and are described in the table below:
Calculus (C 1-3)
Gingivitis (G 1-3)
Furcation (F 1-3)
Mobility (M 1-3)
1
<1/3 Crown Coverage
Mild
< ½ under crown
Up to 0.5mm
2
<2/3 Crown Coverage
Moderate
> ½ under crown
0.5mm to 1.0mm
3
>2/3 Crown Coverage
Severe
Through & Through
>1.0mm
Prior to Cleaning
Prior to cleaning, calculus attachment should be recorded. An average for the quadrant as a whole rather than on individual teeth. However, should one tooth (for example) have a vastly different Score to the Quadrant, then that should be recorded adjacent to the tooth on the Chart. An example of this is an upper 4th premolar with a Calculus Score of 3 in a quadrant that has an average score of 0-1.
Post-Cleaning Assessment
Gingival Score (GI 1-3)
This score is given to assess the extent or severity of Gingivitis seen. The more severe the erythema and oedema, the higher the Score.
Probing Depth (mm)
To assess Probing Depth, gently step the periodontal probe in multiple locations around the neck of the tooth while keeping the probe parallel to the crown of the tooth – place the probe gently until resistance is felt and take your reading. A helpful tip is to know the length of your probe (i.e. 10mm, 13mm, 15mm or 18mm) and when the probe is placed into a pocket, simply count backwards from the length of the probe which will give you the depth of the pocket. This then is recorded onto the Chart in the location that the pocket is found. Remember that normal sulcus depth in dogs is up to 3mm, and in cats up to 1mm and these don’t need to be recorded.
Gingival Recession (GRmm)
Measure any Gingival Recession and record at the location found on the Chart.
Furcation Exposure (F 1-3)
Furcation exposure is measured by placing the tip of the Periodontal Probe between the roots of the multi-rooted teeth to assess the extent of bone loss and gingival attachment loss.
Mobility (M 1-3)
The mobility (movement) of a tooth is measured by the distance that the tooth moves by applying pressure with the elbow of the Periodontal Probe.
Step 4: Record Radiographic Findings
Dental Radiographs help to diagnose all oral pathologies seen in small animal patients, and not just what it is but to what extent.
Tooth Resorption (TR) – since we find tooth resorption in other species, we no longer use the abbreviation FORL. You’ve saved 2 letters!
Oral Masses (OM) – drawn on Chart in correct location with OM written beside.
Step 5: Treatment & Notations
All treatment performed is recorded on the Chart – remember that this includes the Professional Dental Cleaning (PRO) and Radiology (RAD) performed.
Extraction – X marks the spot! When a tooth is planned to be extracted an oblique line is marked through the tooth on the Chart. Once the tooth has been extracted, it is confirmed on the Chart by a second oblique mark – making the ‘X’ that often represents an extracted tooth.
Sometimes, there is not a simple way to record what you have seen or the treatment you have chosen. In this instance write short notes on the Chart for clarification.
Step 6: Transcribe & Provide
The final step in the Dental Charting process is to transcribe all of your findings and treatment into the patient record. Scan the Chart as a visual representation of this patient’s assessment and treatment and provide your client with a copy of the Chart. This is a really useful tool in describing the assessment and treatment with the Pet Owner during the Discharge Appointment.
There are many abbreviations used in the shortform recording on Dental Charts. The American Veterinary Dental College website is a great resource for you to create your own language specific to your practice and the cases that you see and treat and can be found at this link: https://avdc.org/wpfd_file/abbreviations/
How iM3 can help
iM3 has a 5 Piece iM3 Ergo Periodontal Instrument set supplied in an autoclave cassette, which includes:
Dental Mirror,
Gracey Curette,
Universal Curette,
Universal Scaler,
Perio Probe & Explorer.
These high-quality dental instruments are designed for veterinarians and feature innovative handles made from soft silicon, which provides comfort and added grip during use. The colour-coded handles help determine the instrument’s shape even at a glance.
For over 15 years Maggie has worked in small animal general practice and we’re sure she’s a familiar face to many in the industry. Her passion for dentistry led to her obtaining the Diploma of Veterinary Nursing (Dental) and the Veterinary Technician Specialty VTS (Dentistry). Maggie has experience in General Practice Dentistry as well as in Specialty practice having conducted nurse dental clinics and assisting in both general and advanced specialty procedures. As an experienced and qualified trainer, Maggie has provided training in dentistry to veterinary teams both domestically and internationally and brings her contagious passion for dentistry to her role at iM3 in providing training and support to our clients.
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