Table 6. Items to Include in the Dental Chart and/or Medical Record

 Signalment

 Medical and dental history, including diet, chewing habits and home care

 Physical examination, medical and dental history findings

 Oral examination findings

 Anesthesia and surgery monitoring log and surgical findings

 Any dental, oral, or other diseases currently present in the animal

 Abnormal probing depths - tooth by tooth

 Dentition chart - note specific abnormalities, e.g., discolored, worn, missing, malpositioned or fractured teeth; supernumerary teeth; soft tissue masses

 Current and future treatment plan - addressing all abnormalities found, initial decisions and changes based on subsequent findings

 Any recommendations given, accepted or declined by the client

 Prognosis

NOTE: Tables 4, 5 and 6 were excerpted from the AAHA Dental Care Guidelines for Dogs and Cats.