Conscious oral evaluation

The conscious oral evaluation is an important first step to anticipating procedural extent and preparing and educating clients regarding anticipated findings while under general anesthesia. In many instances, the examiner will underestimate the presence of disease during conscious evaluation, only to have the full extent of oral pathology revealed by periodontal probing and intraoral radiography.

Examination of the conscious patient can be facilitated by use of individualized pharmacologic and nonpharmacologic protocols designed to reduce anxiety, stress, and pain. For anxious, conscious patients, there should be no hesitation to recommend use of anxiolytics to facilitate an awake oral examination. For established patients, anxiety can be effectively relieved by administering trazodone in dogs and gabapentin in cats, ideally the evening before and at least 2 hr before presentation if deemed safe and appropriate. For new patients who are difficult to assess, rapid-acting sedatives or anxiolytics such as butorphanol, acepromazine, dexmedetomidine, or alfaxalone are recommended. The use of anxiolytics and sedatives should not replace the need for procedure-associated analgesic strategies but will support the analgesic efficacy of analgesic medications. Additional, nonpharmacologic techniques of compassionate restraint that can help facilitate conscious patient evaluation include low-stress handling, use of pheromones, reduction of excess noise, and the use of highly palatable treats as a distraction. These techniques reduce conflict escalation and ensure the safety of the patient, the client, and veterinary staff. Familiarization with techniques described in the American Association of Feline Practitioners’ Feline-Friendly Handling Guidelines is recommended.31

TABLE 2
Items to Include in the Dental Chart or Medical Record

Signalment
Physical examination, medical, and dental history findings
Oral examination findings
Anesthesia and surgery monitoring log and surgical findings
Any dental, oral, or other disease(s) currently present
Abnormal probing depths (recorded for each affected tooth)
Dental chart with specific abnormalities noted, such as discoloration; worn areas; missing, malpositioned, supernumerary, or fractured teeth; tooth resorption; furcation exposure; and soft-tissue masses
Radiographic findings/interpretation
Current and future treatment plan, addressing all abnormalities found. This includes information regarding initial decisions, decision-making algorithm, and changes based on subsequent findings
Recommendations for home dental care
Any recommendations declined by the client
Prognosis

 

All physical exam findings should be recorded in the medical record (Table 2). Aside from general physical exam findings, visual attention should be paid to the head and oral cavity, and the visual evaluation should be performed with appropriate palpation. Specific signs associated with oral disease include pain on palpation; halitosis; drooling; viscous or discolored saliva; dysphagia; asymmetric calculus accumulation or gingivitis; resorbing teeth; discolored, fractured, mobile, or missing teeth; extra teeth; gingival inflammation and bleeding; loss of gingiva and bone; and abnormal or painful temporomandibular joint range of motion. Occlusion should be evaluated to ensure the patient has a functional, comfortable bite.32 The head should be evaluated and palpated including inspection and retropulsion of the globes, lymph nodes, nose, lips, teeth, mucous membranes, gingiva, vestibule, dorsal and ventral aspects of the tongue, tonsils, salivary glands and ducts, and assessment of the caudal oral cavity and gag reflex if it can be safely elicited. Any and all abnormalities (including abnormal swellings or masses) should be recorded in the medical record.

Careful attention to a conscious oral evaluation provides the practitioner with an opportunity to demonstrate oral pathology and educate the client about potential treatment options. Full appreciation for the spectrum of treatment options will likely not be known until additional information can be gathered from the radiographic interpretation and additional anesthetized oral examination findings such as pulp exposure, furcation exposure, tooth mobility, or periodontal pocketing. Pre-emptive discussion of oral findings with the client provides additional time for the client to consider what treatment options may be offered once anesthetized oral exam findings are collected. Periodontal probing for pockets or furcation exposure or dental probing to evaluate for pulp exposure or tooth resorption should never be performed on an awake patient. Inadvertent or deliberate contact with sensitive or painful areas such as the exposed pulp risks hurting the pet and exposing the owner or staff to being bit. Additionally, the pet may become averse to objects being introduced into its mouth. This tends to undermine the patient’s trust in human handlers and is counterproductive to coaching the client to try various home oral hygiene tools or preventive care techniques.