I am pleased that in recent times there has been an improvement in the provision of dental care. Given the known and documented local and systemic effects of dental disease on our patients, for us to truly fulfil our promises made on registration that “above all, my constant endeavour will be to ensure the health and welfare of animals committed to my care”, we need to actively look for problems – rather than expect our clients to present with dental-related issues.
Oral disease is rarely a presenting complaint in small animal practice. Owners often assume that the systemic effects are simply a reflection of Fido getting older and slowing down, or Tiddles being bored with her toys. Quite extreme halitosis is simply written off as normal “dog’s breath”. The owners’ lack of awareness has in the past been compounded by the lack of interest from the veterinary profession to take dental disease seriously over decades. There is still a lack of proper training in our university courses (there are still currently no general dental specialists employed by UK universities). The majority of dental procedures are not classified as “acts of veterinary surgery” by the RCVS. Some practices still regard “dentals” as a very poor second cousin, the dirty op to be squeezed in at the end of the shift after the “proper” operations of neutering, etc. Given this institutional downgrading of the importance and relevance of dental disease, it is little wonder that owners have followed the lead of the veterinary profession in disregarding dental problems.
Given the frightening statistic that 80 percent of dogs and 70 percent of cats over the age of three need dental treatment (Logan and Boyce, 1994), you could simply play the odds and assume that every presented patient needs to be admitted for treatment. A better approach is to ensure that every patient at every consultation has a thorough oral examination. So, rather than waiting for the annual vaccination and health check, go looking for dental disease all the time. It is difficult to justify anaesthetising Fido to stitch up the cut, or Tiddles to drain the abscess, when a week later a colleague is recommending an anaesthetic to sort the unnoticed, or unrecorded, dental disease.
History and signalment
The signalment can provide helpful guidance. Just to name a few examples: brachycephalic patients are more prone to dentigerous cysts (Figure 1), younger animals are more likely to have issues with the temporary dentition, Sphynx cats and Chinese Crested dogs are prone to developmental dental issues, etc…
Is there any history of oral pain? The signs can be subtle. Is eating being performed normally – is it more one sided, or is food being dropped? What is the pet’s diet, any recent changes or dietary preferences? Are pets generally well, or are there other existing disease conditions (eg diabetes or renal disease; Figure 2) which can be compounding factors? Has there been recent weight gain or loss? Even if the pet is presently fine, is there any history of problems in the past? What oral home care measures (eg daily toothbrushing) are currently in place? Has there been any change in the level of acceptance of home care measures?
History and signalment are obviously essential components. Then, as with examining any other area, a logical, systematic approach is beneficial. This way, the chances of things being forgotten or overlooked are reduced.
I like to conduct all my examinations up on a table. Using a variable height table allows me to examine everything from Wolfhounds to hamsters without endangering my back. Most importantly the patients are in my space and tend to be more cooperative than if I was chasing them around the floor.
Generally, having settled the patient and hopefully won their (and the owner’s) confidence, I assess their general appearance. Is the patient obese or emaciated, well-groomed or matted? Is there any asymmetry to the appearance of the head? But be aware that bilateral disease can often occur. Are there any obvious swellings, drainage tracts, discharges or salivary drool? What is the condition of the superficial drainage lymph nodes?
Then on to the oral examination itself. Gently holding the head and palpating the area of the oral cavity may elucidate signs of pain, or reveal swellings masked by a longer fur coat. Using your thumb, the lip over the maxillary canines can be lifted, whilst maintaining safe restraint in most patients. This allows assessment of the thickness of the lip and appraisal of the mucous membranes of the lip and the local oral mucosa. A preliminary assessment of the oral occlusion can be gained and an idea of the level of plaque and calculus accumulation. The local gingiva can be viewed. Is there recession, overgrowth, inflammation, ulceration, overt bleeding or petechiae, localised swellings or masses (Figure 3), sinus tracts? Gentle pressure on the periodontal tissues may express some cheese-like material from the gingival pocket. Demonstrating this “pus in the mouth” can often be helpful in gaining client’s acceptance of the need for dental treatment.
The upper lip can then be raised more caudally to expose the premolars and the more rostral molars. In cats, tilting the head backwards tends to encourage the mouth to open allowing assessment of the mandibular arcades. In dogs, a second hand can pull the lower lip down – whilst the upper lip is still raised. This allows pretty good visualisation of the mandibular arcade.
It is essential to actually count the teeth (Figure 4). Missing or additional teeth are common and can be linked to other pathologies. Additionally, by identifying each tooth in order to count them, the mind is focused and the individual tooth’s appearance and position are assessed and can be compared to a memory of the normal anatomy of that individual tooth.
Is the tooth intact? Are there signs of wear? Is the crown shorter than normal, is tertiary (reparative) dentine visible on the coronal surface, does the pattern fit attritional wear (wear against the dentition on the opposite arcade), or is it more likely to be abrasive wear (Figure 5)? Tennis ball chewing has a distinctive abrasive pattern where the circle of the ball being held is evident on a number of adjacent teeth. Cage bar chewing often results in wear to the distal (caudal) aspects of the canine teeth, often with metallic stains present.
Extrinsic staining (discoloration of the surface of the tooth; Figure 6) can also result from colourants within food material, plaque or chronic oral bleeding. Intrinsic staining (discoloration of the internal portions of the tooth; Figure 7) is often the result of blunt trauma. Trauma leads to inflammation of the pulp, pulpitis. This may result in haemorrhage within the pulp. Free blood cells can then pass into the dentinal tubules, especially if the pulpitis has led to death of some of the odontoblasts and regression of the odontoblast processes freeing space within the tubules. The blood and haemoglobin pigments then undergo the same colour changes we see in bruises. Ninety-two percent of intrinsically stained teeth are expected to be non-vital and the treatment options are extraction or endodontic therapy.
Are there signs of resorption? It is important to remember that dogs suffer from tooth resorption as well as cats. Internal resorption (where the resorption occurs from within the pulp, expanding outwards through the dentine) can be seen as pink spots on the crown of the tooth. External resorption may be identified by seeing an “eating away” of the tooth structure, often at the gingival margin – the cervical, or neck, region of the tooth.
Are fractures present (Figure 8)? The mildest form of damage is a cracking of the enamel (enamel infractions). Enamel fractures just involve loss of the enamel. Enamel dysplasias can result from damage to the developing tooth bud prior to eruption of the tooth, and may result in areas of enamel loss or weakness and staining of the underlying dentine. Uncomplicated fractures have loss of both enamel and dentine but do not expose the pulp chamber; however, complicated fractures involve the pulp chamber and treatment options are limited to extraction or endodontic treatment. A “wait and see/monitor” approach is not permissible ethically as significant pain and pathology will result.
Often, we can get so taken up with the extent of the pathology identified, it can be easy to neglect the opposite side of the mouth. It is important to repeat the process to assess both sides! After this, I then examine the incisors. I find that many pets resent the “face on” approach – so I tend to leave this to last. Finally, I will attempt to open the mouth to assess tongue, hard and soft palates, tonsils, etc.
- Having a structured, methodical approach to an oral examination helps to prevent things being missed
- Communication with the owners is essential and COVID-19 restrictions are clearly a hindrance. An assistant with a mobile phone camera can prove invaluable in relaying information. It is always important to stress that the consultation room examination is a preliminary assessment
- Full examination requires anaesthesia and radiographic evaluation which will be discussed in a future article