Hi everyone, thank you so much for joining us for this session with the webinar vets. We are going to talk through together about the dental oral exam, the dental chart, dentistry instrument and equipment care, and we're also going to look at the hows and the whys of scaling and polishing teeth safely. So my name is Stacey Parker.
I'm a registered veterinary nurse in the UK. I'm mainly a referral, anaesthesia and dentistry RVN and I'm also the owner of Bertie's Boutique veterinary CPD. So the objectives that we're gonna go through together on this session is so that we can understand what must be annotated on a dental chart, understand the tools used and how to use them, and how to, how they assist you, to complete the dental chart.
We're gonna look at some common, sorry, oral presentations that you may see when you're looking in the animal's mouth, and also understanding how to correctly maintain our dental instruments and equip them. We're gonna look at recognising the importance of how to safely perform a scale and polish of the teeth. There is a little bit of a debate whether we should be polishing, and we'll discuss that a little bit later as well.
So first of all, whenever we're doing anything in our patient's mouths, please do wear gloves. I know obviously owners don't, and with your own animals, you're probably, you know, probably touching the mouth and and aren't, but we're touching multiple different mouths and then lots of different equipment and things, and we know that there's a lot of bacteria in the animal's mouth. So please do wear gloves.
And we need to remember it's really important even when we're doing dentistry, that we don't have our dentistry blinkers on, and we're just thinking about the teeth. We need to look at the entire head and the skull and indeed in the bigger picture, the, the whole patient, so. We aren't talking about that in this session, but don't forget, if you're seeing something in the mouth, it, it might be linked to something that's going on in the rest of the body.
So we need to take the patient as a whole, and even when we get as far down as looking at the teeth, we need to remember to include other structures in the mouth and not looking just at the front of the teeth in our dental consultations and such. And a good example is of this little lady here. Now as you see this is the front of her mouth, everything looks quite good on the upper and lower jaw, a little bit of plaque there, maybe a little bit of gingivitis and gum recession.
On the upper jaw and a little bit of maybe crowding on the lower jaw, but nothing that would alarm us too much, really. But then we look at the back of the mouth, and it is quite a different story. And this little lady came to us because she couldn't close her mouth.
Apparently she was chasing a rat. He picked it up, she screamed and couldn't close her mouth, and that seems quite a bizarre presentation. I can't help but feel worried that something's happened.
Are we being given a story that is or isn't correct? But actually this little lady had had a dental check at her usual vet's a couple of weeks before. It had looked like this and said everything's fine, you don't need to do anything good oral health.
But they hadn't looked at the back or they would have seen the teeth looking a bit like this. And unfortunately, they were correct, she couldn't close her mouth because she'd fractured her jaw, due to the amount of bone loss through the periodontal disease, when she did pick up a large rat in her mouth, it, the pressure of that did. Kind of be the straw that broke the camel's back and fractured this dog's straw, so.
Even if it's dental consultation, and particularly when we have our patients anaesthetized, even if they're not anaesthetized for dentistry, it might be a bit different, obviously if you're, you know, in an emergent situation trying to get an airway, but if you've got a lump removal or a spa, a neuter, even, you know, your orthopaedic surgery and things, have a good look in the mouth and make sure there's not something brewing. Because if we saw a leg about to break, we would definitely be advising the owner to do something about it. So why shouldn't we be telling them that there's a potential that the jaw might be about to go?
So it's really good to look at the entire mouth, at every opportunity that you have to avoid these kind of emergency situations. So going back onto our objectives for today, it'd be interesting how many of you, if you have a think amongst yourselves, are completing a dental chart. And is that the vet completing it?
Is it the nurse completing it? Is it one or the other? If it's the nurse completing it, are you taking them away from monitoring the anaesthesia?
That mustn't happen. It's awesome to get nurses involved with dentistry. Definitely.
We can do a lot. We can learn a lot. It's really fun.
But we must not have us doing that in replacement of somebody monitoring the anaesthetic. So there's lots of different dental charts available. Rachel has made her own.
If you would like a copy of the Perry referrals dental chart, we will give them out free of charge. It will still have our logo on. Just email us at hello@ perryreferrals.co.uk and we'll be happy to supply those for you to use.
And don't worry, they do have a key on the back which describes what Rachel was anticipating to be an annotated on that dental chart. So we've seen a dental chart, but why is it a good idea to do a dental chart? You know, you're busy enough as it is, you just wanna crack on.
It's really important that you do complete a dental chart for every patient as it will provide a snapshot of the mouth at that time. And the veterinary surgeon in charge of that patient can make their treatment decisions based on the results of the dental chart, the dental radiographs, and any preoperative clinical examination and history. So for us, we'll fill in a dental chart and then we take our X-rays.
And then Rachel will have a look at the two along with the clinical things and the physical exam that she's been looking at at the patient and its mouth, and then can make an informed clinical decision on everything that she's seen. You don't have to remember what was going on with every tooth. It's all there in pictorial form in front of you.
It's not so helpful if you just complete this on the one off and then it's never saved anywhere. It's important that this should be scanned onto the system for future use and also to show the owner a picture of what the mouth was like and what was going on. I also think it can help you in any unfortunate legal situations because if you didn't record it and you're saying that it was in this state, this is how the tooth had, it did have this vacation.
If you didn't record it, where's your proof that it happened, and we all know if you don't write it down, it didn't really happen. So you need to make sure that you are annotating everything and ensuring that that is saved on the patient's file for future use. Really important as well to use a species specific dental chart, so a canine dental chart and a feline dental chart.
We also have a puppy dental chart because their dentitionians will be quite different, so we have that as well. So before you reach for your dental chart, as I said earlier, please pick up your gloves and pop them on. So you must be sat nice and comfortably when you're performing the dental chart.
It can take you a little bit of time. And you're not gonna be, you know, you're not gonna be performing your best if you're sat uncomfortably. So sitting comfortably is super important and holding the tools in the correct way.
Having a table that can go up and down or a chair that can go up and down so that you can get nice and comfortable in a position over your patient with a nice straight back. Your elbows aren't up in the air, so you're nice and comfortable. So to start with a dental chart, you're going to need a periodontal probe, and that's going to be able to measure your periodontal pockets and have a good look at the mouth and the teeth and the gum line, and you're able to use that periodontal probe to go under the gum and into the gingival sulcus.
So these can sometimes just be an instrument that has one end or they can be, have both ends, dual ended, and have a different type of instrument on the other end. So the one that looks a bit like Captain Hook, that is a . Explorer probe, you can see that that's quite sharp, so that must not be going under the gum line.
And I'm gonna show you in a moment in some videos how and in what situation you would use either or both of these instruments. But when you start charting when you're looking for periodontal pockets and you are going under the gum line, make sure you're only using your periodontal. Instrument, your periodontal probe, and you are not using that explorer probe because you can see the damage that can be done.
It's it's very sharp. So when you're holding the periodontal probe as you saw in the picture of Rachel earlier, you should be holding it in the modified pen grasp, which is a grasp used for many instruments. The handle is held with the pads of the index finger and thumb, and the middle finger extends down the shank, and the fourth finger used as a finger rest.
This position will allow you to have good tactile sensation. In the rigid version, the index finger is moved up the handle with a straight joint to allow more strength for scaling or correct work. So I think it's really important to practise holding your pen like that, and seeing the dexterity that you have along your wrist and the comfort that that can bring, and you can use your little finger and the one next to it to rest on the patient's face or on the table.
And if you're practising now holding a pen like that, I'd like you to now hold it in a really firm sort of almost fist grasp and see how much dexterity you lose and how much tactile sensation and how it's actually quite uncomfortable. And by remembering to keep your little finger and maybe the next one on the table or on the patient's head, that keeps you comfortable and keeps your elbow down. And if you're holding a pen now, practise holding your elbow up in the air and see how quickly your upper arm and shoulder will get fatigued.
So back to our periodontal probe, as we discussed, this has a narrow rounded or flat blunt graduated end, and it can be inserted into the gingival sulcus without causing trauma. So this guy is used to measure periodontal probing depth, determine the degree of gingival inflammation, evaluate urcation lesions, and also evaluate the extent of tooth mobility. So this guy can tell you a huge amount of information.
And this is a little video of it being used. I know. So it's with a gentle touch, we aren't, you know, forcing or stabbing it anywhere, and it's really important to go the entire circumference of the tooth as well.
We don't show you all of that in this video, but every tooth you should go the entire way round and we show you a particularly good example of why that is so important shortly. So back to the other end of our periodontal probe that I showed you earlier, the Explorer probe. So this is used on the, crown, on the crown area of the tooth, only, not under the gum line.
And this is gonna show you about any enamel defects or cavities or any indents or, yeah, anything going on on the upper surface of the tooth, because you'll feel it catch or, or fall into these little crevices. And that's why it's quite sharp so it can show you any of these concerns. Yeah.
So here it's being used on a fractured tooth, and you should only ever use these instruments, this and the periodontal probe on patients that are under anaesthesia. So now we know the main tool we want to use to complete our dental charts. As I said, it's not just about looking at each teeth, and each tooth rather, but we will be looking at the entire mouth.
So we're gonna go through some examples of what you might see in the mouth regarding the mouth and the teeth, and then we'll follow on with the usual dentistry annotations as well. So maloclusions, these are best checked with your patient without their breathing tube in. So if you have a patient that you've noticed has a maleclusion preoperatively and you want to assess the degree of that maoclusion, once they've had their sedation, a little bit of induction agent, that's a good time to carefully have a look at what's going on and how the mouth closes naturally and where they may have tooth on tooth or tooth on soft tissue structure, abnormalities, and you can work out what treatment might be needed.
If you're not sure and you want to take pictures, this is a really good time to take pictures to send to a veterinary dentist. And with the mouth closed, but the lips parted, so we can see sort of a game of Tetris, how those teeth are trying to fit together and direct you as to what treatment may or may not be needed. So we used to say overbite, underbite, that was kind of confusing confusing because it would be, well, is the upper jaw or the lower jaw the over or the under.
So we've placed it into classes. So class one maoclusion is what may be called a lance canine. So the jaw length of our patient is correct, but one or more teeth are out of alignment.
It's more common in dogs and in certain breeds of dogs. You can see it in cats as well, though, as you can see from these images. Now, I know we said you must wear gloves with all of your patients, and we do.
A lot of these pictures were submitted to us from owners who understandably don't feel the need to wear gloves when putting their fingers in their, their own, pet's mouth. So yes, that, that's where those pictures are from. This is a class 2 maleclusion.
This puppy is upside down, just to confuse you a little, but often that's when the owners are able to get pictures when their puppies are asleep. So Class 2 maleclusion is a jaw length discrepancy when the mandibles of the lower jaw is shorter than the maxilla. This is quite common.
It is something that must be treated. We shouldn't just see how it goes. When the puppy is sleeping, that's when their jaws want to, that's when they do all their growing.
Including their jaws, and their mouth closed when they're sleeping, that lower canine, it can get trapped in the upper jaw, preventing if the puppy has any more potential to have a slightly longer lower jaw, it won't be able to reach that potential because it's trapped. And it's also really painful, and you can end up with these big divots in the top of the mouth. And this is really painful, as you can imagine.
Imagine closing your mouth, and every single time. That lower tooth is going into the roof of your mouth, it must be so painful. A lot of these puppies are super head shy, or they may want to play with toys more or carry things more because when they carry something their mouth isn't closed and it's not painful.
So when it gets to this level, not only is the lower jaw not allowed to grow anymore and it's painful, we've now potentially got a connection from the palate up to the nasal cavity, so a neuro nasal fistula. That's never good. We're gonna get bacteria at the back of the nose, and that's gonna cause erosion and pain and infection.
And also this upper left canine, the 204, is gonna be at risk of damage because it hasn't got a full gingival seal. Because we're now gonna have bacteria able to get down to the root of that tooth, which is not what we need either. So you can see the pickle that leaving this can occur.
There's different types of class 2 maoclusion and different treatment choices. So again, if you're having a case and you're unsure, take lots of pictures, send it to a a friendly veterinary dentist, and they can guide you as to what they would recommend and at what age. Then we have the Class 3 maocclusions, which I don't think are quite as common as the Class 2, but this is where the lower jaw, the mandible, is now longer than the upper jaw, the maxilla.
So this can sometimes just be a little bit unsightly, or they look a bit like the graffilo. So the upper incisors can sometimes cause painful indentations on the lower jaw on the gums sort of sap. Behind the lower incisors, sometimes it's just very minor and they've sort of grown into being comfortable, but sometimes it can be really quite uncomfortable as well.
You may be seeing trauma to the upper lip. So again, case by case basis as to whether that needs to have any treatment, and there's some other examples of our class 3. Then we have our class 4 manocclusion, and this is more uncommon I would say, jaw length discrepancy where one of the mandibles or on one side of the lower jaw and not both, is shorter than the maxilla, and it really gives off this quite wonky appearance.
Now this might be OK if everything's happy, it's not touching anything or causing any trauma, and every single malocclusion, as we've said, is going to be slightly different. So we need to see what we need to do, whether we need to do a gingivoplasty, so we remove a little of the gum to make an area for the tooth to sit, or if we need to be extracting any teeth or if any orthodontics are required. So moving on to another element that I think you may see quite a lot is retained deciduous teeth.
So some of them have a lot, like this little dinosaur on the left, and sometimes it's just the canines are dealt with and they shouldn't just be left, and they should be dealt with under dental radiography. Enamel hyperplasia is often confused for staining or stubborn plaque that just doesn't come off when you're cleaning. So enamel hyperplasia is a defect that occurs during tooth development where the enamel for some reason just hasn't come through at all or come through very well or it's not very strong, so it's been chipping off, leaving this dentting that acts like a sponge that's taking on the stain, and then you see these horrible brown lines.
So these should be treated by a veterinary dentists to place some sealants on. Because the enamel's normally nice and shiny, and it's not gonna hold on to lots of bacteria and plaque, but the dentin is slightly rough and does act like a sponge, so it may take infection through to the pulp. And it's a rough surface that obviously bacteria and plaque are gonna breed and cling on to quite happily.
So you are, compromising their periodontal health if we don't place sealants on them. Keep an eye out for fractured or worn teeth. Worn teeth are generally a bit more smoother, fractured tends to have a more jaggedy area, and the worn teeth often have a little black spot where the tertiary dentting have been building up.
Seen particularly in dogs that like doing fly ball or carrying tennis balls, or, have been in crates, unfortunately. And then the fractured teeth with cats tends to be from sort of high rise falls, and then dogs, normally if they've had access to incorrect items such as antlers, pebbles or. Stones or rawhides or.
All the things that are far too hard for our patients to be put in their mouth. We should also be annotating if there's any missing teeth, because they may never have erupted. They might have been previously extracted.
They might have fallen out through resorption, or they might have actually fractured and the root is left below the gum line. Also, if the tooth is set below the gum line and just never decided to come out, then this can cause a dentedous cyst, which is a fluid-filled structure, which causes bone destruction, as you can see there. So the first premotor is under the gum line, it hasn't popped out.
It's created a lot of fluid under the gum line. This is now destroying the jaw bone and is affecting the premolar too, and also the root of the canine is starting to be affected there as well. So, super important if you can't see a tooth, that you recommend that the dental X-rays to make sure that this isn't going on.
This dentedist would just get bigger and bigger and bigger, destroy more of the jawbone, and potentially you will then see a jaw fracture, and you're gonna be losing some really important teeth, such as the canine, and you then could be going further back to start losing your carnasal teeth. Really important to annotate what you're seeing under the tongue, especially with cats. They're quite good at having these horrible cancers grow under their tongue, or they might have areas of lesions where a tongue is sore because it's been rubbing on a sharp tooth that you might not have noticed or a heavy area of calculus.
So make sure, particularly because cats and dogs aren't so good, particularly cats letting you look under their tongue, unless they're under anaesthesia to take this opportunity, as I said, under any anaesthesia to have a good look at the mouth, particularly under the tongue. And this is probably a picture you're all very, very familiar with, so calculus plaque builds up into tartar, which is calculus, which is this thick. Yellowy, hard.
Stuff that you just can't remove with brushing, so this does require a professional clean scale, ultrasonic scale and polish. You may be seeing areas of gingivitis or inflammation of the gum line. And also, we should be looking at annotating tooth mobility, vocation exposure, pocket depth, gingival recession.
You should be annotating what teeth you've extracted today. And as I said, not just focusing on the teeth, but the whole area. So feeling the lymph node sizes around the heads and skull and mouth, and the synthesis, looking at the oral mucosa.
What colour is it? Is there any, pigmentation? Is there any ulceration?
Have a look at the tonsils on intubation. Are they swollen? Is there any pustules?
Any concerns there? And also looking at extra teeth, so not just the retained baby teeth, the deciduous teeth, but any extra teeth, because sometimes they can have two teeth, where there should be one, and it's not that it's deciduous, it's an extra. So we call those a supernumerary tooth.
So we're gonna talk you through some of those bullet points now. So the mandibular synthesis in cats is always meant to have quite a degree of laxity, that can be quite normal. We do have a lot of cats referred, where lots of suture material or wiring has been used for the synthesis in the cat that actually it was very normal.
So they, it's normal, particularly as they get older to have this kind of laxity. OK. Looking at a gingival index next, you would be marking that as 0 with a clinically healthy gingiva.
One for mild gingivitis, which would be slight reddening and swelling of the gingival margin, but no bleeding on gentle probing of the gingival sulcus. Level 2 would be moderate gingivitis, so the gingival margin is red and swollen, and on gentle probing of the gingival sulcus, it does bleed. And then 3 is the worst, the severe gingivitis, so the gingiv margin is really red and very swollen with spontaneous bleeding, with ulceration of the gingival margin can be seen.
This is the level, the highest level. You can see it's incredibly sore and ulcerated and this is bleeding all on its own. So we spoke about using our periodontal probe to ascertain probing depth, so you will have a graduation on your periodontal probe.
They're all different depending on what brand you have. So make sure you know what numbers mean. So gently insert the graduated periodontal probe until resistance is encountered at the base of the sulcus and make sure you go around the whole circumference of the tooth.
The depth from the free gingival margin to the base of the sulcus is measured in millimetres at several locations around the circumference of the teeth. The normal gingival sulcus for a cat is 0.5 to 1 millimetre and in dogs, 1 to 3 millimetres deep.
Anything deeper than that is termed as a periodontal pocket and indicates the presence of periodontitis. So be aware that gingival swelling or gingival hyperplasia will also result in increased probing deaths, but that might not be due to periodontitis. This is called pseudo pocketing.
So if you've got a massive swelling of the gingivarel or you've got gingival hyperplasia, commonly seen in your boxer dogs and such, that is going to be a fake pocketing because a degree of that shouldn't be there anyway. So you just need to bear that in mind. So we'll have a look here why it's so important to go round the whole circumference.
So this is the one we saw earlier. So we're having a look at the buckle aspect, so that the area closest to the cheek and then the very same tooth on the lingual aspect, so the side closer to the tongue. OK.
Quite the pocket. OK? So if we'd just done on the buckle aspect, we would have missed that.
You would have seen it on X-ray for sure, but, if you're already at your charting point, you know that we're probably looking at extracting, you can start being preemptive about your local blocks for this. So moving on with our dental chart, tooth mobility. So we're looking at different grades of tooth mobility.
So 0 means it doesn't move at all, which is fantastic. One is your horizontal movement of 1 millimetre or less. 2 is your horizontal movement of more than 1 millimetre, and 3 is vertical as well as horizontal movement.
Multi-rooted teeth are marked more severely, and they're therefore going to tolerate less mobility. So we can see here. Definitely a 3, that's definitely coming out.
Fircation exposure, so this is where you have a multi-rooted tooth and the circation is the areas between the roots, they shouldn't be exposed. So when they are, that's called a focation exposure. Zero grade is there's no ocation involvement.
Obviously that's what we want. One is the initial ocation exposure, which means it can be felt with the probe, but the horizontal tissue destruction is less than 1/3 of the width of the ocation. Focation grade 2 is partial ocation exposure.
The ocation can be explored with the probe, but the probe cannot be passed through the focation. Horizontal tissue destruction is more than 1/3 of the width of the ocation. And then 3rd, the 3rd grade is total ircation exposure.
The probe can fully pass through the ircation from the buckle to the lingual aspect. So we'll show you a couple here, one we saw earlier with the grade 3 change for inflammation. All the way through that, OK.
So occa exposure, that tooth is going to need to be extracted. What is this, is this a tooth indeed. So we had someone watching us from a different discipline who hadn't had a lot to do with teeth, so they were quite shocked.
That was a schnauzer to see that degree of calculus that was clinging on probably double the length of the tooth, and then see it that mobile and with the focation exposure. So when we've been in the dental chart, all our teeth are numbered. And I know that when I first met the Trident numbering system, and even some days when I'm feeling quite tired, it's a bit overwhelming.
There's a lot going on. You're already trying to make sure you've got everything set up and you've got 5000 things in your mind, and then you've got someone saying numbers to you, or you're looking at the teeth and trying to work out the numbers. So it is a really handy system to have.
It provides a consistent method of numbering teeth across different animal species, and it's really important because if you think you have to write about everything about every tooth, how long it would take you to write, the upper right canine had some abrasion, it had a complicated crown fracture, it had a pocket of 3 millimetres on the buckle aspect. And so on for every single tooth, there's 42 teeth in a dog's mouth, that is gonna take you most of the day. So in order for that not to happen, we can fill in our dental chart using the Trident numbering system.
So I always have to pretend that I am the dog, and I think my upper right starts with 1, so 104 would be my upper canine, for example, upper right canine. Then I'm moving around my mouth in an anti-clockwise fashion in my brain, but when I look at the patient, it's clockwise. And then to the upper left it begins with 2, the lower left starts with 3, and the lower right starts with 4.
So we just break that down a little bit further. If you're struggling to remember how this works, try and remember the 12, 300, 400, and it's free information where you're doing deciduous denttic and it goes round again, and the upper right starts with 5, and then 6 and 7 and then 8 as you go round. So the last two digits are annotating what tooth?
So the first digit is annotating what quadrant of the mouth that is in, and the last two digits are annotating what tooth it is. So if we remember that ending in 04 is always always a canine tooth, the 08 is always the upper carnassio, which is the last pre-molar, and the 09 is the lower carnassial, which is the first molar. That will hopefully give you some orientation as to where you are in the mouth, particularly when you have patients coming in that have already got teeth missing.
So it's important to remember how many teeth are in the adult dentition. Our feline patients have just 30, and our canine patients have much more at 42. This doesn't change the numbering system, so the numbers will still be used in the same fashion.
And you can see here the red are the ones that the cats are missing in comparison to dogs. So the 04 and the yellow is still your canines, the 08 is still your carnassios, and the 09 on the lower jaw is still your carnasio and your first molar, and it's still your first molar upper or lower jaw. They don't have a 105 or a 205 on the app jaw, but it doesn't mean that the next, the first premotor that they do have is called the 05.
We still use the numbering system as if they had the full confirmation of teeth. So we have 104 as a K9. They don't have a 105.
The first premotor in a cat is a 106, and that still caused the first premolar. But then dogs, the first premotor would be the 105. So that took a while to get my head around.
They don't have a back molar, a second back pre-molar on the upper jaw. They don't have a 1:10, so that's the red line there. And they also don't, they only have one lower molar in the lower jaw.
So you can see they are in comparison to dogs. They don't have, 310, 3:11, or the 410411. They are missing in the lower jaw not missing.
They just, I'm not meant to have it in comparison to dogs though, they don't have an 05 or an 06 on the lower jaw on both sides. So that's something to try and get your head around because it's so easy to try and call, for example, the 407, the 405, because it's the first premolar you see, but it's actually not, it's the 407. So this is a dental chart that's been completed for, I think this is for a Pomeranian.
You can see there is a lot going on, there's lots of lines, lots of shading, lots of numbers, what's going on? It can be a little bit overwhelming. So let's break that down.
These yellow highlighted areas, the one line through them means that these teeth need to be extracted. So that helps you keep track when you speak to the owner as to what work needs to be done, so lots to be extracted here. Are green ones that Rachel has shared in already, these teeth have already fallen out.
This dog had never had a dental, but these were falling out due to periodontal disease, so all of these teeth are missing. These guys are talking about the periodontal pockets, so this is the occlusional surface of the tooth that you can see as you look down at the tooth, and Rachel will shade the area where the periodontal pocket is and write the depth of it. So this is a really quick, easy way to get those pockets written down.
So there's a lot going on there of very deep pockets. This is in green, this is all the teeth that have got a degree of mobility. So all of these teeth, and you can see they're also the ones that have got the line through them pretty much, they all need to be extracted, they're all mobile.
And these ones in orange, these are all ones that have got aurcation exposure and they're all furcation exposure 3, so the probe can go all the way through. So on our dental charts, people often ask what these guys are for, the GMOF and P, and this is what it means. These are grouped together as there are periodontal disease indices.
So they're gonna really help us establish whether we need to extract this teeth, these teeth rather. So G for gingivitis, M is for mobility, O is for other, F for ocation, and P for pocket. So with all that information together, we can then have a really good idea of what's going on with that tooth.
So we've covered quite a lot in the first part of this session, and it's really important to understand the different areas of your teeth so you know what's going on and the importance of dental charting and understanding what you're annotating, not just filling it with a load of numbers. So this is a really good book that I have found useful for learning more about dentistry. And for me, I work quite Well in pictorial form.
So I've drawn the big picture of a tooth and I have coloured it in, and then I have done this on repeat with tracing paper until it's in my head. And then I have, done a key annotation to it so that I can remember which part is which. And this might help for your owners as well, if you can make it look a little bit more professional.
So moving on to the second part of our session, we're gonna be talking about instrumentation and equipment care, and I think that's something that can get missed, particularly in a busy practise. We just don't have time to be doing everything. We're pushed our patient care comes first, but this does have a lot to do with patient care because it's going to enable you to do your work better and more efficiently.
The biggest question we get asked is how often should we sharpen our instruments. Well, it's gonna depend how often in the heavy use of the instrument. If you've just done one tooth extraction, it might be all right not to have to sharpen it immediately.
If you've used it for a full mouth extraction, you're definitely going to be needing to, sharpen that periosteal elevator, for example. If you haven't used the kit a week and it just happens to be on a weekly checklist, but so you're gonna get them out and sharpen them regardless of the fact that they haven't been touched. That's probably not a good idea, because remember that every time we sharpen these instruments, we are removing a little bit of the metal each time.
So if you haven't used them, there's no need to sharpen them. So, as we said, minute particles of metal were removed at every sharpening and at each use. We are aiming to restore the sharp edge of the blade whilst maintaining its original shape so that the tool can continue to do its job.
Blunt instruments are no good, they're gonna mean a lot more work for the surgeon or the RBN, and they are going to cause damage to your patient's tissue and will prolong surgical time. If you've got a blunt scalpel blade, for example, you'd happily replace it. But we don't sort of look at identity instruments in the same way unfortunately, even though they're made to be very sharp and be cutting.
It's gold standard to lightly sharpen every instrument after each procedure to avoid blunt instruments. I'm making sure they're sharpened until the cutting edge can engage on something plastic as a test, so maybe a syringe barrel for example. If you're using it, you should be using the stone to sharpen these, they should be wiped down after every use and use a different area of the stone each time.
And remember that you're sharpening stones aren't gonna last forever. And neither are your instruments. They will need to be replaced at some point.
Some people like to sharpen them with oil, which will lubricate and remove friction and give a nice surface finish to the blade, but it's not a necessity. And just remember that you can do a really good job and sharpen these tools beautifully and then just chuck them all back into a basket to go. They're just gonna bump against one another and get all blunted and damaged.
So if they're a sharp instrument, they should be nicely laid out in trains, and if not, they should be in a little carriage or with swabs over their sharp ends, so they're not going to be damaged and not all piled on top of one another. Perhaps they should be all standing up in their instrument storage, not laying down, being squashed. You can get rubber caps to put on to sort of protect yourselves from sharp instruments, but every time you pull them on and off, you may be blunting your instrument ever so slightly.
Not sponsored by anybody, but these guys have got some really good videos and content on their websites as to how to look after each type of instrument. The videos I'm about to show you are via IN 3 with their sharpening blocks and their instruments. If you're buying instruments from somewhere else, you need to ask them how those instruments for them should be cared for and sharpened because it can vary.
Finally, we have the periosteal elevator that is used to lift gingival flaps. This is sharpened using the smiley face technique, as for the ergo range. The stainless steel variety of elevators and oxators are sharpened using a stroke technique.
Hold the sharpening stone vertical and angle the inside of the blade at 45 degrees. Move the sharpening stone upwards against the blade in one motion, approximately 2 to 3 strokes after each use. So that's with regards to the perilote elevators and the luxator.
So we're now gonna talk more sort of general care for our dental instruments. So the first thing is to hand scrub the blood and any debris off and get them nice and rinsed. Do that as soon as you can after they've been used, and we don't want.
These guys just left in a pot of water all day, they will start rusting, and we certainly don't want to see them looking like this either, because we will cause damage to our instruments. And these are really expensive, and as we said, we want them to work, and to last as long as we can before they need naturally replacing. Step 2 is to then clean them with an enzymatic instrument and equipment cleaner using a hand brush or ideally an ultrasonic cleaner.
They should then be rinsed well under the tap, and then you should be drying them using a lint-free material. So we use some nice fancy tea towels. You then don't get lots of lint from tissue and stuff left on them.
It's more environmentally friendly because we can pop these in the washing machine and we use them over and over and over. And ensure that when you're drying these that you haven't missed anything and that each of these instruments are nice and clean. It's a really good time at that point as well as step 5, to double check for any damage.
These guys do get damaged. They've got blunting or scratching or maybe the tip of the scissors or the forceps has come off, and these will need replacing. So anything with a box joint should be lubricated, so at this point we will be doing our instrument care, so we'll be lubricating box joints and we will be sharpening our instruments.
And again, double checking that they are safe for use and that our sharpening hasn't caused any damage either. When we're happy we're gonna get these guys packaged in there. We have surgical trays so we have a cat.
A cat tray, a large dog tray, and a small dog tray. Our swabs, when we're doing extractions are sterile, sterile swabs. So we have these in packs of 10, nice small ones for cats, larger ones for dogs.
And then our elevators luxators are kept in their little carriages so they're nice and safe, and they're also, sterilised. Make sure you have your indicator strip to make sure that they have been sterilised and our periodontal probe we keep separately. Just in case we don't have to do any extractions, yes, it's rare, but then we haven't opened a whole kit and wasted, you know, all the packaging and having to put them back through a cycle.
So we do keep our periodontal probes, sterile separately to be used for the initial oral exam under anaesthesia. All packaged up. We're now gonna sterilise these guys.
Once they're sterile, we're gonna get them out of the autoclave and we're gonna pop them in storage. They shouldn't be anywhere that constantly picking up the aerosol in on their packaging from other dentistry. These guys are nicely stacked because they're all in their metal boxes.
It's safe to stack them. They're in a nice clean cupboard, they're organised, we can see what they are, and then that cupboard is closed to stop any debris or bacteria getting on them. So that's our instruments, we'll now move on to the dental unit.
Everyone's dental unit is gonna look very different. This is our one that we have at the moment that has a compressor attached that's just off to the left a little bit. So with regards to the dental machine, it should be wiped down every day and in between patients.
We know how much bacterial aerosol we create through dentistry, and also it should be serviced yearly. The water supply should be changed daily. Don't just keep topping it up because you've got old water just sitting at the bottom and always use distilled water or purified water and please check that that water supply is working before you anaesthetize your patient.
We use a microbiological cartridge from Iron 3 called the Iron 3 straw, and this prevents the biofilm from building up within the internal plumbing. We change this annually, but please do follow the instructions. It does need a little bit of time to be set up, so you do it at a time where the machine is not about to be used.
And then after this has been, followed the instructions, you need to make sure you flash it through so the initial cleanse that this will give is no longer in the lines before you start with your patient. It's really different between veterinary and human dental care, so that the hand pieces that they're using. The water supply is tends to be for the crown of the tooth, so you're not really looking at the pulp as much.
Whereas we're doing a lot of, use some work on the bone, obviously removing bone for our extractions and such. So we, that's why we have to be careful what cleaning material we use, because it is going to be going near bone in the bloodstream. It's a little bit different in human dentistry because it's mainly on the crown, so they're not entering that.
So they are a bit different and can use much stronger cleaning supplies. When you do refill your dental machines with, your water, please make sure it's distilled or purified water only. They can look really similar to other bottles, such as surgical Spirit, and we can always, all of us can be time pressured or busy.
And there was a report in, I can't remember where it was. The dog that had had a dental, and he went home and it was just really crying all the time and I think it was a greyhound, they thought he was just being a bit dramatic. But they looked in his mouth and it's really sore, and they took it back and they'd realised that they had filled up the dental machine with surgical spirit.
And not purified water and and done the scale and polish, so all the liquid going over the gums that will so and extraction sites and stuff had had surgical spirit on instead. So be very, very careful. I'd recommend that you store these in completely different areas of the hospital and annotate them even further than what the original label gives you if needed.
The compressor may be a part or it may be with or built in to your dental machine, but we do need to look after it and make sure that we release the pressure each evening when we're done and then do it back up. These should be serviced by your supplier yearly as well, and these also needs to be cleaned between procedures. If they're in the same room, obviously some are in a different room.
So with regards to your dental unit, hopefully if it's got, it will have suction on, I recommend having suction available for all dentistries. If it's inbuilt, then make sure you are rinsing, the suction cup, but don't get the philtre wet because then it kind of works in a backwards fashion, it's a bit broken. So you should be wiping down all the cords, all underneath, every surface because that act that aerosol full of bacteria will reach everywhere.
Suction tubing should be cleaned between every patient, if you're doing further. More advanced dentistry such as root canal and such, you know, using bleach, then don't leave bleach in them, it will deteriorate and split the material. These do need to be disinfected, there's some special suction.
Cleaning fluid that you can get for them and then they must be rinsed a lot, and then make sure they're hung so they dry fully. Really important that you check these for cracks after every use and keep a spare, you don't want to have your suction suddenly breaking on you. You don't know when it could get caught on something or decide just to split, so make sure you keep a spare one in the cupboard.
And as I said, if they had the suction philtre, make sure that it doesn't get wet. So our hand pieces are really expensive, but they do so much work. They're really good.
We do not want to be letting them down. So we should ideally be changing the bears after every patient because we, they do blunt quite quickly, and that means you're going to put more pressure on to try and make it work better without even realising, which will put pressure back on the motor of the handpiece. And I've worked in hospitals where they've done a lot of dentistry and there's multiple people using them and, and not so much responsibility for the machinery has been taken.
And the handpie break all the time because we're reusing birds over and over over too much pressure and then they break, which is a shame because they are very expensive and it's unlikely that you have a spare. These do not get submerged in water, and if you do have a bear that's stuck, don't push down on the burr and try and get it out that way or bang it around. Get an old pair of extractor forceps and you should be able to put it out that way.
These must be lubricated after each use, and we'll show you how to do that, and they must be cleaned with a wipe, over on the exterior surface, and these can be autoclaved as well. We'll show you that. So these are the wipes that we use, make sure it's appropriate for the material of your handpiece and then we also lubricate them.
So this is Rachel showing us how to do that. So we're gonna lubricate these dental hand pieces. This is a high speed hand piece and this has a 360 degree swivel.
So we can lubricate it in one of two ways. We either need this attachment on the, the spray can, on the lubrication, and we would put that into the smaller of the two big holes. And then Just put some tissue around the end.
Give the aerosol a shake and then we can put that in there and you'll hear the turbine turning. The other way to do it, and you need the proper attachment for this, which you would get from the manufacturer. So this is a WNH hand piece, so from WNH we get the right adapter.
That goes into there and then the end of this goes into the end of the adapter, and then we do the same thing. That's it. For the low speed hand pieces, so we've got a straight one and a contra angle one, they have a slightly different adapter.
And that again goes into the end of the hand piece and then we can lubricate straight into that. The same with this one. So into the e-fitting.
And that is it, it's all it needs. So you can have a look on your hand pieces for these signs, it's the autoclave sign at what heat it can go up to, and that means that you can place it in the autoclave, which most people don't know. And the same with your scalar tip at handle, sorry.
So these guys should be able to clothes as well. It's really important with your scalar tips that you're checking their wear. They are normally overused.
So when you buy your scalar tips, they should come with this tip wear guide, and this will show you, when you hold the scalar tip up to it as to when they're done. So when they get to the, the Red Cross, that means that they need to be replaced. So they don't last forever, they do become quite brittle.
The last thing we want is that breaking in their mouths, and we actually had a colleague of mine, she walked past it one day. And I thought, Oh, something's caught me, and that was it, carried on with the day. And the next day we went to set up the dental room, couldn't find the scale of tip.
It was a branch practise. We only had the one. And, she was like, it's weird.
Like, my arm's been hurting, it can't be in there. And I was like, No, of course it isn't. But we then put my magnet on her arm, and it stuck, and we sent her off to A&E, and the skinny tip was in her arm.
So please look after your instruments. You should have a new sterile scalar tip for every single patient and be ordered to and be careful, sorry, to order the correct tips because some can go under the gum line, some can't. And as I said, check the tip wear guide regularly and keep them in their cases to avoid damage as well.
So I have a moment to reflect back before we move on to the last piece of the session about what changes you would maybe like to make in your own practise, regarding, filling in dental charts, the understanding of what you're doing with that, what you might see in the mouth, and also how you're looking after your instruments and equipment. Are there any protocols that you might like to change? If you want to learn even more, this book is really, really good, I'd recommend it highly.
So moving on to the last segment of our session today, we're gonna discuss scaling and polishing. And it's not quite as in depth as as we think it could be. So, first of all, as always, please wear PPE, mask, goggles if you don't wear glasses, a, a hat, definitely gloves and an apron, and wearing scrubs underneath.
So if we break it right down to the basics, why do we scale teeth? Well, we're scaling them to remove the calculus, and the calculus is what you can see with your naked eye. It's a build up of plaque and it's hardened.
So we need to make sure that we're scaling the teeth very safely because it is something like with all treatments that can cause damage if done incorrectly. So first of all, we need to ensure that the airway is protected and as we mentioned before, we should be holding this with a modified pen graft. So ensuring the airway protected means a throat pack, tilting the head slightly lower.
And making sure that throat pack is obviously removed, before we finish, and changing it regularly as it will get saturated, and also, having suction on hand. So holding it in the modified pengrasp, do maybe hand scaling. I hope you don't have to do that.
But we should be checking that the water is working first on our ultrasonic scalar. Otherwise we will cause, thermal burns to the teeth if we're not, using water, because it does produce a lot of warmth because it's continually vibrating. The gentle pressure it really is less is more.
So if you press harder, the end of the scaly tip can't constantly be bouncing back and forwards, vibrating, and that's what breaks everything down. So if you push harder, you're stopping it from doing what it needs to do, and it won't work as well. You'll just damage the tooth, get frustrated, and probably, cause trauma to your tools as well.
You were only to use the lateral surface of the tip, not the pointy edge on the tooth, and it's best not to stay on an area for too long. Now, I don't like to give a particular time, because it, if there's a thick level of plaque, you, you may be able to stay there or calculus rather for, you know, 2 seconds. But if there isn't really much, you probably don't need to be hanging around that long.
Work methodically that works best for you. If you need to go back round the mouth, that's fine, but whether it works for you to start at the upper back, on the right or at the front. Depends what position you like your patient in.
And we've discussed how to hold it. And this is how you should be scaling and also showing you that scaling can be uncomfortable, so you may need to be looking at improving your, analgesia as well. The jaw chattering is not normal on scaling, so if you're seeing this, then you should be looking at introducing, further analgesia.
And as a reminder, please make sure you are ensuring that these guys are checked regularly. You should not be using the, spring loaded gags. They will cause post-op blindness in cats, and they're very uncomfortable, and we, we don't need to use them.
You can get good enough visualisation by using a cut down one mil syringe for your dogs and for cats using a cut down needle cap so you can have a good look, and it's not going to be putting that damage on the nerve, which will then stop, the nerves and the blood supply potentially going into the eye and causing post-op blindness. Finally, let's discuss polishing. Should we or shouldn't we be doing it?
It's a big debate. If you are not doing it, make sure you're not charging your patient or saying to your owners, we're doing a scale and polish. If you aren't doing it, you need to be comfortable with your decisions why you're not.
Normally it's because they, people are saying, well, it all builds up within a few hours. Yes it does. But if you've got a patient that you think the owner is gonna be able to do really diligent home care, why wouldn't you leave them in the best possible position to get that working well?
Polishing can cause damage, but so can scaling teeth. So can placing an IV, so can intubating your patient. It's all about doing things correctly.
So the reason that polish is that it will remove stain, and it will remove plaque and bifilm that you can't see with the naked eye. It does not what people have said historically, it does not smooth out scratches made by scaling. We think about it, should we be accidentally scratching the teeth when we're scaling?
No. And do we want to remove even more enamel down to the point of that depth of a scratch to make up to that scratch? Absolutely not.
So it should be performed using a very low speed, it should not sound like a lawn mower or a hedge trimmer. You can turn down the speed of your scaler and of your polisher. Try it on your thumb first to test the speed and you'll be alarmed and surprised at how uncomfortable it can be quite quickly.
Always use a fine grain gra grade toothpaste, and you know may be wondering why, if you always have to use fine grade, why is that coarse grade even available? That's used for more, advanced procedures when you're having to place acrylics and things on the teeth, so you need a little bit of friction. But when you're genuinely polishing teeth, it must be with a fine grade toothpaste.
Just like the scaling, please use a light pressure and spend a short amount of time on each tooth. So we've got a little video here to show you. There's different types of coffee cups available, you can get sort of soft little red cups or you can get the ones that are more slide on.
It depends on the, on the hand piece that you have and if you want the contra angle or not. So dipping back in and out to get your toothpaste is fine, working the whole way around the tooth. You don't wanna, you wanna be working on the gum line gently as well.
And all surface of the tooth, and as you can see it's perfectly OK to go back over instead of spending a long time on one tooth. So that has covered our little dentistry session. Thank you so much for joining us.
If you have any questions, you're very welcome to get in touch. My email is Stacey at Bertie's Boutique.com.
That's B U R T Y, Bertie Bertie's Boutique.com, about any questions you may have. And thank you to the webinar bet very much for having me, and I hope that this has interested you.
Giving you some inspiration to make some positive changes or confirm that you are doing things, within your comfort level and doing them well. So thank you so much for joining us.