Medical record example

AI-Generated Veterinary Dentistry

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Example Medical Record

Dentistry

Benny

Thursday, July 30, 2026 at 4:07 PM

Dental Note

Indices

  • Periodontal Disease: PD3 suspected – moderate periodontitis with an estimated 25–50% attachment loss based on probing; to be confirmed with dental radiographs.
  • Perio Pockets (probing depth): 5–6 mm pockets at the maxillary fourth premolars and first molars bilaterally; 4 mm at the mandibular incisors; <3 mm elsewhere.
  • 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.

Recession and Furcation

  • Gingival Recession: Mild gingival margin recession noted in lower incisors; exact measurements not obtained but <2 mm estimated.
  • Osseous (alveolar-bone) Recession: Not assessable without radiographs; bone loss estimated from probing depths and attachment loss.
  • Furcation Exposure: Grade 1 (F1) suspected at the left maxillary fourth premolar (208); no furcation involvement detected elsewhere on clinical exam.

Tooth Pathology

  • 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.

Soft Tissue

  • 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.

Other Pathology / Findings

  • 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.

Summary

  • 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.

Performed Today

  • Pre-anesthetic blood work panel submitted; results pending.
  • Core vaccines updated: DA2PP and Bordetella administered.
  • Physical exam completed; cleared for anesthesia pending bloodwork.

Plan

  • 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.

Extractions Planned

  • Upper and lower incisors (12 total): Grade 2 mobility with attachment loss; not expected to be salvageable.
  • Posterior teeth (premolars/molars): Extraction dependent on radiographic findings; potential concern for advanced periodontal loss on left maxillary arcade.
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