Animal Dentistry & Oral Surgery165 Fort Evans Rd. NE, #106Leesburg, VA 20176P: 571-209-1146F: 703-662-6186animaldentalspecialist.com

Tooth

Triadan

Pocket

Recession

Furcation

Calculus

Plaque

Gingivitis

M1 P4 P3 P2 C I3 I2 I1 I1 I2 I3 C P2 P3 P4 M1

109 108 107 106 104 103 102 101 201 202 203 204 206 207 208 209

RIGHT LEFT

Tooth

Triadan

Pocket

Recession

Furcation

Calculus

Plaque

Gingivitis

M1 P4 P3 C I3 I2 I1 I1 I2 I3 C P3 P4 M1

409 408 407 404 403 402 401 301 302 303 304 307 308 309

Date

N A - Extraoral/facial

N A – Lymphnodes

N A – Buccal mucosa

N A – Tongue

N A – Palate

N A – Tonsils

N A – Pharynx

Plaque Index 0 1 2 3

Calculus Index 0 1 2 3

Gingival Index 0 1 2 3

Owner: Pet's name:

Ref. veterinarian: Pet's breed:

Ref. hospital: Pet's age: Pet's sex: F/S M/N

DENTAL RECORD

Maxilla

Mandible

R L

DIAGNOSIS

MAL/2 MAL/3 MAL/WRY Malocclusion/base narrow mand. canines Mal/anterior, posterior crossbite Supernumerary tooth Deciduous tooth Retained deciduous tooth No perio dx (maybe calculus) Gingivitis (no bone loss) Mild periodontitis (< 25% attach loss)Mod periodontitis (< 50% attach loss) Severe periodontitis (> 50% attach loss) Gingival hyperplasia/Enlargement Gingival recession (mm) Stomatitis/MucositisStomatitis/Mucositis - Contact ulcerOral mass: OM/EPA OM/EPF OM/EPOOM//MM OM/FS OM/SCC OM/OS OM/AD OM/LS OM/PAPDentigerous cyst Missing teethPeriapical lucencyPerio pocket (mm)

MAL/1MAL/BN

MAL/ABX, PBXSNDTRD

PD0PD1PD2PD3PD4

GHGR

STMSTM/CU

OM

DTCO

PALPP

Attrition/abrasionEnamel/defect, hypoplasiaCariesTooth resorp./Internal Tooth resorp./External replace Tooth resorp./Cervical root surfaceTooth resorp./External in�am. Retained tooth rootTooth/avulsed, impacted, luxatedTooth fracture( EI, EF, UCF, CCF, UCRF, CCRF, RF )Tooth/non-vital, vitalGranuloma/buccal, sublingualEosinophilic gran./lip, palate, tongueForeign bodyOsteomyelitisLaceration/buccal, lip, tongueJaw fracturesSymphyseal separationCleft palate, Cleft lipOronasal �stulaOrally exposed resorptive lesionTMJ/dysplasia, fracture, luxation

AT/ABE/D, H

CATR/I

TR/ERTR/CRTR/EI

RTRT/A, I, LUX

T/FX

T/NV, VG/B, L

G/E/L, P, TFB

OSTLAC/B, L, T

MN/FX MX/FXSYM/S

CFP CFLONF

RLTMJ/D, FX, LUX

Nerve Block 0.5% Marcaine Right LeftInfraorbital ml mlInferior Alveolar ml mlMental ml mlMaxillary ml mlLocal In�ltration ml ml

Rads (dental, CDR, CT scan, plain �lm)Photos (digital, 35 mm)Biopsy – incisional/excisionalCulture/sensitivity

Periodontal prophylaxisSubgingival curettageBone curettageClosed root planingOpen root planingGingivoplastyAlveoloplastyApical repositioning �apCoronal repositioning �apLateral sliding periodontal �apCrown lengtheningBone graftGuided tissue regenerationSplint/acrylic, composite, wire reinforced

Root canal therapySurgical root canal therapyRoot resection (crown intact)Tooth partial resection (hemisection)Crown reductionVital pulp therapyDirect/indirect pulp cappingCrown amputationApexi�cationApexogenesis

Restoration/composite, GI, amalgamDentinal bonding

Flap mucogingivalExtr. – closed, no sectioningExtr. – closed, w/sectioningExtr. – open, surgicalIntercept ortho (perm/dec)Oronasal �stula repairCleft palate repairCleft lip repairPalate surgeryMandibulectomyMaxillectomyFrenoplastySymphyseal separation/wiringJaw fracture repair (j. fx. rp.)Pin j. fx. rp.Plate j. fx. rp.Screw j. fx. rpWire j. fx. rp.Cerclage wire j. fx. rp.Interdental wire j. fx. rpOsseous wire j. fx. rpSuture lacerationOral surgery/mass removal

Core build upCrown preparationCrown metalImpressions/modelsInclined plane/acrylic, composite, metalOrtho appliance – installOrtho appliance – adjustOrtho appliance – removeOrtho app./bracket, button, elastic, wire

RADY

B/I B/ECS

PROSC

BCTRPCRPO

GVAVP

F/ARF/CR

F/LCRLBG

GTRSPL/AC, C, WIR

RCRC/SRRXTRXCRR

VPPC/D PC/I

CRAAPXAPG

R/C, I, ADB

FX

XSXSS

IO/P IO/DONF/RCFP/RCFL/R

S/PS/MS/XFRE

SYM/WIRFX/R

FX/R/PFX/R/PL

FX/R/SFX/R/WIR

FX/R/WIR/CFX/R/WIR/ID

FX/R/WIR/OSLAC/R

OS/MR

CBUCR/P

CR/MIM

IP/AC, C, MOAI

OAAOAR

OA/BKT, BU, EC, WIR

Pet's name:

TREATMENT

Maxilla

Mandible

R L

DIAGNOSIS:

TREATMENT:

INSTRUCTIONS AND MEDICATIONS:

FOLLOW-UP:

Thomas P. Chamberlain, MS, DVM, DAVDC Curtis A. Stiles, DVM, DAVDC