The Dental Chart

Recording the condition of all teeth as well as soft and hard tissues during the ORAL ATP® visit is necessary to provide quality care. The charting of existing conditions provides basic information for an accurate, comprehensive treatment plan.

Download a non-computerized canine/feline dental chart.

Computerized dental chart

Completed example of a computerized dental chart

What to Include:
  • Dental history — Has the patient had professional oral treatment in the past? What is the patient's diet? What is the client doing for home dental care?
  • Occlusion abnormalities
  • The amount of plaque and calculus present
  • Tooth abnormalities
  • Periodontal abnormalities — Inflammation, gingival edema, periodontal pocket depths, attachment loss, gingival recession or hyperplasia, furcation involvement or mobility.
  • Proposed/declined treatment
  • Actual treatment
Helpful hand instruments include a periodontal probe, explorer and dental mirror. Excellent lighting and magnification are also necessary to clinically evaluate the oral cavity.

Remember, both a general head examination and an oral exam under anesthesia are essential for thorough charting. Generally, the mouth is charted before cleaning and can be recharted if a significant amount of calculus has been removed.

Four-handed Charting

Two person ("four-handed") charting is a fast and efficient way to record oral diseases and conditions. One person examines the mouth while the other records information on the chart.

Be sure to:
  • Evaluate the mouth for presence of plaque and calculus on the teeth.
  • Examine for missing teeth and place a circle on the chart around missing teeth.
  • Note enamel and dentin fractures, including pulpal exposure if present.
  • Insert a periodontal probe with millimeter gradations at the interface between the free gingiva and tooth surface. Advance the probe gently to the bottom of the sulcus or periodontal pocket and "walk" around the tooth. Record abnormal measurements at the four corners of each tooth.
  • Note attachment loss and probe depths on the chart.
  • Observe and record any other lesions.

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