The dental chart is a permanent record of a patient's dental care including dental history, tooth abnormalities, radiographic findings, periodontal examination, proposed, actual, declined, and future treatment plans as well as home care instructions.

Recording the condition of all teeth, as well as soft and hard tissues, is necessary to provide quality care. The charting of existing conditions provides basic information for an accurate, comprehensive treatment plan.

A thorough clinical examination must be conducted to complete the chart. Helpful hand instruments include a periodontal probe, explorer, and dental mirror. Excellent lighting and magnification are also necessary to clinically evaluate the oral cavity.

The dental chart includes:

• Dental history- Has the patient had professional oral treatment in the past? What is the patient's diet? What is the client doing for home dental care?
• Skull type (brachycephalic-flat faced, mesaticephalic-medium faced, dolichocephalic-long nosed)
• Occlusion abnormalities
• The amount of plaque and calculus present
• Tooth abnormalities
• Radiographic findings
• Periodontal abnormalities including inflammation, gingival edema, periodontal pocket depths, attachment loss, gingival recession or hyperplasia, furcation involvement, and mobility
• Proposed/ declined treatment
• Actual treatment
• Future treatment plans
• Home care instructions including proposed re exam appointments

HOW TO CHART

Before anesthesia the animal is given a general head examination with attention to structures around the mouth (facial swellings, painful areas, lymph nodes). The mouth is opened and shut to check for pain, crepitus, decreased range of motion, and occlusion.

Anesthesia is essential for thorough examination and charting. To evaluate each tooth individually, complete immobilization is necessary. Generally, the mouth is charted before cleaning and can be recharted if a significant amount of calculus has been removed.

Two person (“four handed”) charting is a fast and efficient way to record dental disease. One person examines the mouth while the other records information on the chart. Under anesthesia, charting begins with evaluation of the mouth for presence of plaque and calculus on the teeth. Next, the mouth is examined for missing teeth. A circle is placed on the chart around missing teeth. Enamel and dentin fractures are then noted, including pulpal exposure if present. A periodontal probe with millimeter gradations is inserted at the interface between the free gingiva and tooth surface. The probe is gently advanced to the bottom of the sulcus or periodontal pocket and “walked” around the tooth. Abnormal measurements at the four corners of each tooth are recorded. The attachment loss and probe depths are noted on the chart. Finally, other lesions are observed and noted.

1. Examine rostral and distal occlusion before intubation, record abnormalities.

2. After intubation, examine the mouth and circle all visibly missing teeth on the dental chart.

3. Record any fractured teeth.

4. Check for tooth mobility using an instrument handle pressed against the tooth. Record abnormal mobility (M1, M2, M3).

5. Record amounts of plaque and/or calculus accumulation.

6. Record abnormal probing depths and/or attachment levels around each tooth.

7. Expose and process dental radiographs where indicated.

8. Clean the teeth.

9. Reprobe, if a significant amount of calculus is removed.

10. Formulate a treatment plan through tooth by tooth evaluation-draw a diagonal line though teeth which need to be extracted, record a “PCT” (perioceutical) next to teeth which can be helped with local antibiotic application.

11. Calculate fees for the treatment plan and contact the owner for approval while the technician is completing the teeth cleaning process.

12. Once the owner approves, complete the initial treatment and record all care on the dental chart.

Click on any chart to see a larger version

CANINE DENTAL CHART

FELINE DENTAL CHART

ORAL HYGIENE VISIT - Completed Dental Chart