Patient assessment, evaluation, and documentation

History and Physical Examination

A thorough history of patient health should always include an evaluation and update on systemic maladies as well as an evaluation and review of oral hygiene efforts performed by the pet owner. Proactive management of oral health includes documenting any efforts by the client to provide home dental care. These include tooth brushing; type of diet fed; access to “chews,” treats, and toys; information on chewing habits; and updating any current or previous professional or home dental care. A thorough physical examination should be performed to evaluate all body systems regardless of species, breed, age, health status, and temperament. Patients presenting for complaints separate from the oral cavity should be evaluated for the primary complaint. Appropriate diagnostic tests and treatments should then be recommended. Patients with underlying health conditions should be appropriately assessed so that general anesthesia associated with dental or other procedures can be safely performed.