Canine Dental Evaluation Template - The Carolinas Animal Hospital
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1Katherine E. Queck, DVM
Fellow, Academy of Veterinary Dentistry
13331 York Center Dr. Suite “A”
Charlotte, C 28273
Marguerite Gleason, DVM
704.588.9788, Fax 704.588.5781
Canine Dental Evaluation and Plan
Date ____/____/____
Patient Name__________________________Last Name______________________________
Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
CA
Caries
GI1
Mild gingivitis
OM Oral mass
CI1
Slight calculus
GI2
Moderate gingivitis
P # Periodontal pocket mm
CI2
Moderate calculus
GI3
Severe gingivitis
PE Pulp exposure
Cl3
Moderate calculus
GR
Gingival recession
RD Retained decidious tooth
CRW Crown
H
Hyperplasia
RT Rotation
F1
Furcation exposed
M1
Slight tooth mobility
RR retained Root
F2 Furcation exposed
M2
Moderate tooth mobility
SN Supermumerary
F3 Furcation exposed
M3
Severe tooth mobility
X
Extracted
Fx Fractured
O
Missing tooth
EL Enamel loss
Plan_____________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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