Good morning and welcome everyone to the Essential stream. I do hope you enjoyed the keynote address from Ian Chapel, Perontal Systemic Disease Connection. If you have logged on late, because of doing morning surgery, please do go back and watch it.
It just an amazing, presentation on periodontal disease and the connection with systemic disease. If you wish to switch between the streams during the day, please refer to your email from the webinar vet which contains the access links. But all the webinars will be available to watch on demand from lunchtime tomorrow.
It gives me great pleasure to introduce our, second speaker of the Essential stream, Hannah Van Valelsen, who, is a practising veterinary surgeon and currently working towards an ESAVS postgraduate certificate in dentistry. I would also like to thank, our partners for the day, Mars, Pet Care, Eichemeyer. A Somerville's, IM3, MAI, Hills, the Veterinary tissue Bank, Accesia and Covetris, without whose support today wouldn't be possible.
If you have any questions for the presenters during the event, then please do use the Q&A. Box at the bottom of your screen, and assuming there's time, we'll try and answer them all at the end of the presentations. Hannah's talk today is clinical examination and charting, a logical approach, and I will hand you over to Hannah.
OK, I've already managed to embarrass myself by starting halfway through. Thank you so much, Paul, for introducing me. As I said, as he said, my name's Hannah.
I, I'm a first opinion practise, and I'm basically I'm quite excited to kick off our essential stream today. And, really taking us back to the basics, of our real just to start clinical exam, charting, and really getting everything ready to create all of your awesome treatment plans. Ah, why are we here today?
Not just today at the BVDA scientific day, but also just generally sitting through my lovely presentation. I think we can all agree that over the past couple of years, dentistry in veterinary medicine has really been evolving. It's moved from a, if in doubt, take it out to So much more than that.
We have so many more possibilities to save teeth, to alter mouths, to increase patient comfort and do so much more than we used to be able to, and I think we're all appreciating just how interesting this field is. And with that comes, I think the acceptance that the way we used to do things isn't probably the best way of doing things. We all want to be better.
That's part of why we're all here today. And really that high standard that we want to achieve is only ever going to be possible if we do get our basics right. So that's why you're in my lecture today.
Those basics, they're not just important for whoever's on the stream today who's really just starting out with dentistry. I hope there's a couple of people here as well who are a little bit more advanced already, but also keep in mind that their basics are really important because at the end of the day, 70% of what you're going to be doing with your patients is going to be those basics. All of your patients are going to need.
Examination of the teeth. All of your patients are going to need thorough cleaning of the teeth, and all of your patients are going to need X-rays. And it's not till after you've done all those things that you can really start doing kind of the cool stuff like your endodontics and fracture pairs and maoclusion treatments.
Most of the patients that you're going to see are going to be animals with periodontal disease and they really need a good workup. That's the start for everything. So basically your basic bit, step by step is your conscious examination when you've got the patient with you in the consult room.
At the moment, not with the owner, but normally that would be with the owner as well. Followed by your anaesthetized examination, unfortunately, as we all know, our patients aren't quite as good as human dentistry. So we do need to anaesthetize our patients to really get a good look, and some really important parts of those are the visual exam, charting and recording all of your findings and doing a thorough radiological exam as well.
And then your last part of your basic startup is doing a thorough cleaning of the mouth. Today I'm gonna, I'm gonna kind of leave the conscious exam behind us a little bit, those that have been at my previous version of this, webinar. Quite a long webinar once I get into it, once I get started about teeth, I won't stop.
So I'm going to skip over the conscious exam a little bit and just take us straight into an anaesthetized patient. But that being said, I'd like to introduce you to our patient of Today, this is Kiko, who's an absolutely lovely Siamese cat who I met earlier in the year. He is a neutered male.
He's a reasonable age for a Siamese. He's 16, but he's taken on pretty nicely, got a lovely body weight on him. And his presenting complaint was that his owner had noticed that his breath had become a bit smelly.
He wasn't playing with his toys as much. He likes to play fetch and he wasn't really doing that. And intermittently, a couple of times a day, the owner had noticed that he was kind of chewing.
If he had something stuck in his mouth and was really uncomfortable. And, and I knew from his history that about 3 to 4 years before I saw him, he'd been to his own vet and he'd had numerous extractions there, including 3 of his canine teeth, and he'd recently been to his own vet and they'd recommended him to have a repeat procedure. The owners were a bit hesitant because he'd had some complications with wind breakdown on his last dental, he was getting a bit older, and that's part of the reason they came to see me with him.
Now I think we can all agree that his own vet had pretty much given the correct advice by looking at this, I totally agree, this cat needs a dental procedure. We can see there's quite a couple of teeth missing, some from his previous procedure, some were just missing, and There's a lot of tartar buildup there. There's quite some bad gingivitis, and we can even see some signs of hyper salivation there as well.
So we've definitely got some discomfort and problems going on in that mouth, and well worth looking into and seeing what we could do to make Kiko feel better. So once we have here on the table, that's our first step, is to do a really thorough anaesthetized examination. When we are doing a conscious exam, it's impossible to really look at a tooth and say from looking at it, how bad that tooth is.
The goal of our anaesthetized exam, however, is to establish the definitive disease stage that a mouth is in, and that's through a combination of looking at the teeth, probing them, and X-raying them. And that these days will vary per tooth. Each tooth in the mouth is going to be doing something different, but overall, you'll be able to give a bit of an impression of, is it a bad mouth, is it a good mouth, where are we at?
But by getting that definitive disease stage for each tooth, you will be able to set up a treatment plan per tooth from that point onwards. Now the one thing that is really, really important is to note all of your findings from these examinations into a dental chart. And the reason being that your dental chart is your official record of all of your findings and disease stages on that day.
So it's not only providing you reasoning. As to why you, for instance, extracted some teeth, but it's also noting down what stage the teeth that you left in the mouth were on that day, that as time goes on and you do repeat examinations of these animals, that you know what is happening in the mouth, how are things developing, and how good have my treatment plans actually been. This is a chart type that we see a lot, where we just put a cross on the teeth that we took out and as you can imagine, that is not a good example of a clinical chart.
It needs to have everything on it. I'll use examples later through in the lecture. I have a very specific charging structure for myself.
I can sometimes get quite forgetful, so I like to make structures of things to help me remember to do everything. So the first thing I start doing is I write down all of the crowns that I can't see. And that's because once I really get into writing down all my findings, I just start writing from left to right on my chart, and I forget that I need to skip teeth if crowns are missing.
So that's always my first step. I write down which ones aren't there, then I calculus score, score the gingivitis, probe, and write down anything else that I can find. It's important to find a structure that works for you and it's going to help you to remember to do all of the steps.
So it might not be this exact structure. You might choose not to calculus score, for instance, you might choose to do the probing and the gingivitis at the same time and do those before you write down which crowns are missing. And play around with it and find something that really works for you.
The same goes for charts. There's multiple different charts available out there. My advice would be print one of each, have a bit of a play around with them and see which one works well for you.
You know, how big is your writing, how much are you writing down, where do you write things down? Do you need more space? Do you need a different chart?
Find something that works for you and suits you particularly well. So, back to our patient, let's get started. So the first step is the visual exam, and there is no more important thing than your eyes in your examination.
And so the first thing you do is open the mouth and have a really good look. And I've got a lovely picture from one of my other patients, which just goes to illustrate this, and this is a little dog who came in. And he had horrible dental disease, and he'd had horrible dental disease for quite a while, but his main complaint was that his owners had noticed that his breath had gotten particularly worse in the past 3 to 4 months.
And the first thing we noticed when we opened his mouth was this lovely rubber band that had wedged itself between the 4094. Or 10 and it's probably been sitting there for the majority of about 3 to 4 months, causing the increase in halitosis. So that immediately explains the findings that the owner had seen we removed that and then we could move on with things.
So you might find some quite exciting things just by using your eyes. Once you have a little bit of a look in the mouth, my first step, as I said, is to do the calculus scores. Not all dentists will do those.
I think there's a general discussion on how useful they are. I think I completely agree that when we look at the calculus itself, the calculus that's forming on the crown surface of the tooth isn't adding into the problem and the disease around the peridonsium. And, and therefore in itself isn't going to be a good indicator of whether that tooth is diseased or not.
The reason I do quite like making notes of them is that it is a good illustration to the owner as to how much time plaque is allowed to sit on a tooth. So it's an easy way for the owner to be able to see what are the worst areas in the mouth. And also, particularly if it's an ongoing case that I'm seeing quite regularly, build up a calculus will give me an idea of where owners need to spend more time brushing.
So I like to make a note of it as that is. So for instance, looking at Kiko's mouth here, I would do scoring as follows. So the 109, the 108, they are basically entirely covered in tartra.
There's nothing to see there of the tooth itself. So they both get a 3. The 107, 104 are missing.
They've previously been extracted. And that little 106 pre-molar there, . This is really where magnification really comes in.
So I would recommend anyone to use loops for their dentistry, because visually just looking at that tooth doesn't look too bad, but once you've got the magnification on board, it was quite easy to see that that tooth was actually covered for about 40 to 50% in tartar and plaque. So that's why that one's gotten a 2 score on the calculus. The gingivitis scores, I said earlier, can be much more important part of our clinical exam because it's giving us an idea of how much inflammation and disease is going on there.
A zero score is quite a rare score to see. It's probably something that you will pick up on very young patients, and you, you may see quite frequently on incisors in cats which somehow tend to be very clean. And reasonably healthy, but it is very, very rare to see a zero score.
It's much more common to see a 2. That's probably the number you will end up writing down the most. And 3 on occasion in very, very bad mouths, 1 every now and then, but 2 is quite a common score to find in gingivitis, and it's giving us an idea of how inflamed the ginger.
And and how much reaction there is to plaque in a sub gingival space, which is the first step really to the formation of periodontal disease. So if again, if we look at keko, I think we can appreciate that on that P4 and M1, there's quite a lot of gingival inflammation there and it's not surprising that once we start probing, that it started bleeding, so those required 2 score. Surprisingly enough, despite the extrusion slash gingival recession on that canine.
And that little bit of information when we probed it, it didn't actually bleed, so that therefore, gets a 1 score, so just that little incisor to 407 is missing, previously extracted. Then there's the other findings, and when we talk about other findings, I literally mean basically anything abnormal you've noticed in the mouth. And mobility and gingival recession are quite important ones because those are very clear examples and signs of periodontal disease.
We've got bone regression, bone loss, that's going to make teeth more mobile, and it's going to probably lead to some degree of gal recession as well. So if we definitely write those ones down, but anything. Else that you can see as well, gingival enlargement, which is a better term for what we used to call gingival hyperplasia, which actually histological diagnosis.
So enlargement's a better term for that. Any deciduous teeth or suprannumerary teeth, any oral masses that you find like the cat in the top right, and that's a very small mass, but it's actually squamous cell carcinoma. If you've got contact mucusitis, like the dog on the bottom left, that's an important thing to write down.
As well, because that in itself is something that needs treating as well. Any maocclusion, like the dog in the top left picture, and any dental fracture should be noted as well. No matter how small they are, it is important to write them down.
So for instance, the cash on the bottom right has fractured a very small piece of the canine tip off, but that very small piece is enough to allow pulp exposure, and you can always see that there is some alveolar expansion on that tooth as well. So there's some thickening of the ginger. Above it, and that tooth indeed has hip hop exposure and a periaical lesion.
So really, again, good reason to use magnification to pick up any small abnormalities, whether it's missing teeth, small masses, small amounts of mobility, just to make sure that you're not missing anything and structurally moving your way through the mouth, either back to the front or the front to the back, the way you feel comfortable doing. I'm just making sure that you're not forgetting anything. Once you've kind of used your eyes and had a good look around the mouth, the next thing to do is is to use your probe.
So that's going to be one of your most important instruments. Make sure you've got a probe that has a nice little delineation of markings of depth, so it's easy for you to see how deep . The gingival sulcus is, and the reason we're measuring the gingival sulcus is we're, we're trying to figure out if anywhere around a tooth there's any sign of bone loss or attachment loss.
Cats, the gen sulcus is really, really, really tiny and it's actually quite difficult to insert a probe into it because it is generally less than a millimetre. So any kind of depth increase in cats is going to be something abnormal that we need to write down. In dogs, there's a huge variation in breed size.
So where 3 millimetre probing depth might be completely normal for a. Great Dane, it will be an abnormally large depth for a Yorkshire terrier or a chihuahua. So that's something to keep in mind with dogs is as you're moving through the mouth, you may find that if there are a couple of teeth at least that are generally healthy, that those teeth can give you a good idea of what a normal probing depth for that dog is, and anything above that is going to be abnormal and should therefore be written down.
What's really important to remember when you're probing is to use the correct technique for it. I like to call it walk, don't run. So the last thing you want to do is insert the probe into this gingival sulcus and then drag it along the bottom of the gingival sulcus because actually that that can damage that area and predispose to creation of periodontal disease, because those tissues are really quite sensitive and they need to be approached quite gently.
So instead, around 4 to 6 measurements around the tooth, insert the probe and gently push it down to the bottom of the gingival sulcus. Take your measurement, pull it out, move it to the next part. Make sure that you're measuring both on the buckles of the teeth and on the lingual and palatal side of the teeth.
Because even though the periodontal health tends to be better on the lingual and palatal side, there are quite a lot of areas where that's not going to always necessarily be the case, and particularly in some breeds, for instance, your dachshunds that are quite prone to getting palatal bone loss on the upper canine teeth. So very important to always check on all sides. To save yourself a little bit of writing time, only write down the abnormal probing depths that you find.
I used to write down everything, and it makes it very difficult to find the abnormal ones back in your notes, but it also just takes a lot of time and it's not necessarily necessary. So just write down the abnormal depths on your chart. While you're probing, it's really important to also check for any furcation exposures, which is another thing to probe for.
So you want to be checking this on all teeth that have multiple roots, and it's also really important to check from all directions, because sometimes the way that the ginger bar is aligned can actually make it quite difficult to insert a probe into your frication from one side. When you approach it from the other side, it will very easily slip through. So for instance, this is a picture from another one of my patients again and you can see on the more meal premolars, it's really quite easy for me to insert the probe from the buckle side.
And but what the further back I got into the mouth, the more ginger and mucosa was in the way, making it difficult to do that. But when I approached those teeth from the palatal side, I could very easily insert my probe all the way through. So make sure you're checking from all sides and between all roots.
So if you look very good at that M1, that's aurcation exposure between the palatal route and between the meso buckle route, so make sure you're checking that way as well. So once you're finished with all those things, you should have a dental chart that looks reasonably similar to this. So, for instance, when I am writing down my missing crowns, I will initially just colour in the crown part black, and then later when I've confirmed that there is no root remnant on the X-ray, I will colour the rest of the root black.
Forgive me that I forgot to do it on the maxillary side, but you can see how I've done that on the 304, and how on the 309 and the 307, I've left the part of the root open where there is actually a root remnant still present on the radiographs. I'm, if there's any ginger for recession, I tend to draw that in like on the 207, on the 409, on the 404. I've drawn with a line where approximately that gingival recession is so you can see the shape of it back on this chart, and you can see it's on the 409, the 408.
I've written down the abnormal probing depths and which measurement points they are located at. So this chart, together with my X-rays, gives me a really good overview of exactly what Kiko's mouth looks like back in February when I saw him. This is a much better and a much easier chart for me to understand than a chart that just says which teeth I ended up taking out.
I'm particularly on this chart, I have written crosses underneath the teeth that I recommended for extraction. I'm having discussed it with the owner, they decided not to go ahead with all of the extractions due to financial constraints. So in this particular chart, I've circled all of the teeth that I extracted, but I've left crosses on the teeth that I still recommended for extractions, which in the future if Kiko does end up coming back, will make it much easier for me to see which teeth are the ones that I definitely need to be checking up on again.
So not only is it giving me an idea of what I was looking at on that day, it's giving me an idea of what I should be doing in the future should this patient come back. So I touched on radiographs just now as well. So we've done our visual exam, we've done our probing, we've done quite a lot of our charting, and the next step would definitely be to take X-rays.
X-rays are a really important part of veterinary dentistry, so our area of interest is the teeth, and visually we can only see the crown part of the teeth and maybe a little bit of the root depending on how bad the periodontal disease is. But a lot of the part of the animal that we're interested in is not only hidden beneath the surface, but is also on the inside of the tooth. So radiographs are going to give us a better idea of everything that we are able to see with our eyes.
They can confirm and clarify findings of our visual exam. So for instance, here, we've got quite a deep probing depth, and the X-ray very easily confirms that that probing depth is being caused by vertical bone loss around that medial route. So that's one thing they can quite easily do, but they can also give us additional information.
Like this dog here who has some wear of the canines due to tennis balls, and we can quite clearly see much widerontal pulp space on the 304 when we compare it to the 404. And this is something that research has definitely backed up for us as well, and we know that in about 28% of dogs, and about 40% of cats, we would find. And more pathology within the mouth if we are doing X-rays.
So they're a really, really important part of increasing the treatment standard that we are giving to our patients. That being said, it's really important to remember that X-rays are complementing the rest of your examination. They're not more or less important than the visual exam and the probing exam.
Because there are certain diagnoses that we can only make with probing and we cannot make with X-rays like mobility of a tooth and particularly for patients which are probing diagnosis, they are not an X-ray diagnosis. And so, yes, definitely get trigger happy, as it were with the radiographs. Make sure you're taking them, make sure you're getting enough of them, but don't forget the importance of the basics of your examination as well.
It's going to be a nice interesting lecture later from Tom with some case by case X-rays, so I'm not going to spend too much time on them. But I've always find the very important things to remember is if you are X-raying the teeth to make sure that you X-ray all of them. So as difficult as it is to get those little molars at the back on the X-ray, make sure you put the effort in to get them because they're also a part of the mouth where we will very commonly find periodontal disease, and they will help you to plan potential extractions or potential complications before you start doing them.
So make sure you get all of the teeth and also make sure that all of your are what we would call diagnostic quality. When we're doing an X-ray, we're not just looking at the tooth, but we're looking at the crown, the root, the pulp space, and the periodontal space, and the bone structures around the tooth. So we want to have at least a tooth structures visible on the X-ray, and we want that in a correct positioning.
So ideally there's no elongation or foreshortening, so we can really look at the tooth and get a good idea of what's going on in that mouth. I like to start with a standard overview set, so I've got this nice little YM 3 positioning system, which allows me to take full mouth X-rays quite quickly, and it's very easy for my nurses and colleagues to learn as well. And then if I've got any particular areas of interest based on either my visual exam or the initial X-rays, you can then take more views of that specific area at different angles, because that will help you to be able to figure out what is going on with that tooth.
This is approximately what your your X-rays will end up looking like, particularly maxillary x-rays and cats can be quite difficult because of the zygomatic arch getting in the way. And like you can see on the upper left, it kind of overlaps the roots quite a lot, makes it difficult to see. So particularly when I'm doing cats, I end up doing a couple different X-rays from different views of the maxilla like you can see here just to get some different views of the roots and so that I, I can make sure that I'm not missing anything just because of the zygomatic arch overlap.
So once you've got these, a lot of these are confirming some of the findings we found on probing, and some of them will be giving us some new findings as well, so particularly things like the upper little premolar on the upper right side, so the 106 off the top of my head, . That one's got some resorption on there that we didn't pick up on on probing, but it's quite clear on this X-ray on both of the views that we've got, even though it's not entirely on the X-ray there. There's a lot of root remnants from previous extractions that may or may not require attention as well.
Lots of little extra things, but also lots of confirmation of periodontal disease like the lower right molar tooth, the upper left premolar there as well. It's quite a lot of periodontal disease. I'm so got lovely X-rays.
I'm just going to help you confirm but also give you some more stuff to look at. So does that mean it's surgery time yet? It doesn't mean it's surgery time quite yet, before I get to the end of the presentation.
Just a reminder that you do need to clean the teeth quite thoroughly before you then get in there. So as excited as you might be after this lovely logical approach to examination, don't forget the cleaning part of your life as well. The goal is to remove all plaque to improve your surgical hygiene, but it's also a very important part of your treatment plan.
Make sure that you're not only cleaning the crown. But that you're also cleaning, particularly the sub. Area where periodontal disease will start to form, and keep in mind that it is only short term because plaque forms so quickly that if you, it is part of your treatment plan, you need to talk to the owner about the importance of follow-up care as well.
So make sure that you are adding that in as well, but we're going to skip over that today because we just don't have enough time. Hannah. Yeah.
Take home messages very quickly, allow enough time for your thorough explanation. As you can see, there's a lot much more to see and find than you might initially think. Don't skip any of the steps.
They're all important. Make sure you write everything. Down on your chart, and if you can do all of those things right, you can rest easy in the fact that you are providing a very high standard of care for all of your patients, because all of our patients, let's say it, are the special little boys like Kiko is.
Are there any questions? I can't actually see any Hannah, so, I'm still one's now come up. Does excessive tartar interfere with X-ray interpretation?
It does. I, I don't know if there's a little bit of tartar, I might X-ray prior to I'm doing the skin and polish, but I personally prefer to doing my dental cleaning prior to doing my x-rays. So I'll do my charting, I do my calculus score, I get my ginger score and do some probing work.
Then I clean the teeth, and then I'll go back and probe some of the areas again, particularly areas where there was a lot of tartar. It might be getting in the way of your probing exam as well. And then once teeth are nice and clean, I'll X-ray, and then I might actually go back and do a bit more cleaning, particularly if there's some deep pockets that I've confirmed on X-ray, I might go back and clean those again.
Sorry, very briefly, I've just got one more and then we just call a halt, I'm afraid. When do you decide to extract the tooth? I think we've got a good lecture on that later from Annabelle on extractions.
The other one that goes on about extra radiography, we've got, I think that will be covered later for the radiography questions directly. Thank you, Hannah, .