Dentistry Vet AI Scribe

Benny

Periodontal Disease: PD3 – Moderate periodontitis with visible inflammation and bone loss affecting less than 50% of tooth support.
Perio Pockets (probing depth): Within normal limits on manual probing; no pathologic pockets detected.
Gingivitis Index: Moderate – generalized gingival inflammation with erythema and bleeding on probing.
Plaque Index: Moderate accumulation observed, especially along the buccal surfaces of molars.
Calculus Index: Moderate – visible supragingival and subgingival calculus, particularly affecting the premolars and molars.
Occlusion: Normal class I occlusion; no malocclusion or dental crowding noted.

Gingival Recession: Mild gingival margin recession noted in lower incisors; exact measurements not obtained but <2 mm estimated.
Osseous (alveolar-bone) Recession: No radiographic assessment today; presumed stable based on probing and visual inspection.
Furcation Exposure: Grade 0 – no furcation involvement detected on clinical exam.

Mobile Teeth:
- Grade 2 mobility in both upper and lower incisors; movement noted buccolingually under gentle pressure.
Missing Teeth: None absent; full dentition present for breed and age.
Fractured Teeth: None observed.
Tooth Wear: Normal for age; no advanced attrition or enamel loss noted.
Tooth Resorption: No external or internal resorptive lesions noted on visual exam.

Oral Masses: No oral or gingival masses palpated or visualized.
Soft Tissue Findings:
- Generalized erythema of gingiva, particularly along the caudal maxillary and mandibular arcades.
- Darkened pigmentation on the gingiva associated with moderate tartar accumulation; consistent with staining rather than melanosis or pathology.
Radiographs Taken: None performed during this visit; full-mouth radiographs are strongly recommended under anesthesia.
Radiographs (teeth): Deferred; assessment based on gross exam only.

Moderate to heavy tartar accumulation noted, particularly affecting caudal molars and lingual surfaces of premolars.
Gingival margin inflammation and minor gingival recession observed in areas with more advanced calculus build-up.
Mild halitosis noted.

Owner reports intermittent home care, including brushing several times a week, though lower incisors have remained mobile.
Discussion held regarding the progression of periodontal disease and risk of infection or discomfort if loose teeth are not addressed.
Mild oral discomfort during mastication is likely but no overt signs of pain (e.g., pawing at mouth, food avoidance) reported.
Advised that extraction of mobile teeth is appropriate and likely necessary. Posterior dental pathology cannot be fully assessed without radiographs.
Owner was receptive to full anesthetic dental procedure including radiographs and any indicated extractions.

Schedule full anesthetic dental procedure including:
- Full-mouth intraoral radiographs
- Comprehensive scaling and polishing (above and below gumline)
- Surgical extractions as needed
- Post-op analgesia and antibiotics if indicated
Provide discharge instructions including post-extraction care and dietary modifications if teeth are removed.

Upper and lower incisors (12 total): Moderate to severe mobility, no expected salvage.
Posterior teeth (premolars/molars): Extraction dependent on radiographic findings; potential concern for advanced periodontal loss on left maxillary arcade.