Introduction

The field of veterinary dentistry has grown significantly in the last 40 to 50 years. Dentistry is increasingly recognized as a critical part of small animal practice. This in part due to periodontal disease (gingivitis and periodontitis) being the most common abnormality reported to occur in companion animals.^1,2

Dental treatment has increased in range and sophistication.^3–5 The value of full-mouth intraoral radiographs has been well documented.^6–10 The AVMA Professional Liability Insurance Trust has highlighted dental claims as one of the most common reasons for complaints or malpractice legal suits.¹¹

According to the 2019 American Animal Hospital Association dental care guidelines for dogs and cats, “Veterinary dentistry represents an opportunity for a primary care practice to demonstrate a high level of service and professional expertise to its clients and to positively impact patient comfort and wellbeing.”^12,13

The Joint AVMA–Federation of Veterinarians in Europe–Canadian Veterinary Medical Association stated the following on veterinary education in 2020:

At the time of graduation, veterinarians must have the basic scientific knowledge, skills, and values to be a full member of the veterinary profession, and to perform—in an independent and responsible way—appropriate entry-level tasks and duties conferred upon and taken on by the veterinary profession, in the interest of animal health, animal welfare, public health, and societal needs.

Veterinary education must ensure new graduates have sufficient skills and knowledge (competency) in key areas necessary to carry out common procedures expected of new veterinary graduates. Such day one competencies have been described by various organizations, including the World Veterinary Association and World Organisation for Animal Health (OIE).”¹⁴

In March 2018, the American Association of Veterinary Medical Colleges published the competency-based veterinary education (CBVE) framework to introduce 9 domains of competence, each representing a group of related abilities essential to the education of new veterinary graduates. This effort focused on developing “practice ready professionals” for day one in their chosen profession. Every domain has a list of core competencies. The CBVE framework consists of 32 competencies.¹⁵

On November 1, 2020, the AVMA Council on Education (COE) updated the accreditation standards on the veterinary school curriculum to include dentistry.¹⁶ Veterinary colleges accredited by the AVMA COE are now required to include instruction and hands-on dental experiences in their curricula.

The COE Academic Affairs Committee stated, “The Council believes that dentistry is an integral part of veterinary medical practice and is a crucial component for the health and welfare of multiple animal species. It is essential that students are trained in dentistry.”

In response to the inclusion of dentistry as a required topic in veterinary medical education, the Foundation for Veterinary Dentistry (F4VD) and the American Veterinary Dental College (AVDC) formed a committee including dental specialists, several of whom had been in general practice before undergoing an AVDC training program, to define day one core competencies in veterinary dentistry. The members of the Core Dental Competencies committee are listed as authors of this article, in alphabetical order. It is the F4VD’s mission to provide global support and accessible resources to fulfill these standards, competencies, and requirements to benefit veterinary students, prospective employers, educators, and ultimately the global public and animal health worldwide.

The core competencies in dentistry described here fulfill standard 9, curriculum subsection c, of the COE veterinary school accreditation requirements, which states that instruction must include principles and hands-on experiences in physical and laboratory diagnostic methods including interpretation, disease prevention, biosecurity, and therapeutic intervention (including surgery and dentistry).¹⁶

Although the AVDC, with the support of the F4VD, recognizes that veterinary colleges face significant challenges with regard to time and other resources necessary for inserting new material in the curriculum, the AVDC and F4VD consider content described here to be essential for preparation of veterinarians for work in small animal practice. In presenting the information in this article, the committee agreed that it would be ideal if veterinary dentistry were taught at all veterinary schools by board-certified veterinary dentists; however, as was reported in 2017,¹⁷ the F4VD and AVDC recognize that few COE-accredited veterinary schools have a veterinary dentist on staff. At schools not having a dental specialist on staff, basic dentistry is commonly taught in the community practice rotations. The committee recognizes that earning a specialist diploma does not automatically bring with it a superior ability to instruct and supervise and that basic veterinary dental topics can be effectively taught by veterinarians with a particular interest in veterinary dentistry and who are gifted and patient teachers.

The AVDC recognizes that equine dentistry has been undergoing the same significant growth in importance in equine practice as small animal dentistry; the AVDC considers inclusion of some curricular material in equine dentistry to be essential for students intending to enter equine practice. Until the Equine Dental Specialty publishes specific equine competencies, it is recommended that a minimum of 1 equine dental lecture hour be included in this series of curricular recommendations for all veterinary students. The AVDC has requested that its AVDC-Equine specialty prepare a list of curricular recommendations for students intending to enter equine practice.

Recommended Day One Dental Competencies

Using the Domains of Competence format created by the CBVE, the specific day one clinical competency in veterinary dentistry recommendations reported here were drafted and revised by committee members in several cycles until committee agreement on a final version was reached. Many of the individual competencies have been described before¹⁸ and are common knowledge, once one accepts the critical need for inclusion of dentistry in the curriculum.

Domain 1: Clinical Reasoning and Decision-making

• 1.1 Gather and assimilate relevant information about the patient

  Dental subcompetencies:

  1. Gather history (Addenda A and K).

  2. Perform a conscious dental, oral, and maxillofacial examination (Addendum B).

  3. Administer balanced anesthesia for dental, oral, and maxillofacial examination (Addendum C).

  4. Perform a dental, oral, and maxillofacial examination under general anesthesia (Addendum D).

  5. Perform diagnostic intraoral dental radiographs with knowledge of different imaging modalities (Addendum E).

• 1.2 Synthesize and prioritize problems to arrive at a differential diagnosis list:

  1. Ability to identify dental, oral, and maxillofacial pathology.

  2. Creation of problem list based on conscious examination and examination under general anesthesia combined with imaging.

  3. Prioritize differential diagnoses of dental and maxillofacial pathology.

• 1.3Create and adjust a diagnostic and/or treatment plan based on evidence:

  1. Student demonstrates ability to combine history, conscious examination, examination under anesthesia, imaging, and other diagnostic tools to develop a sound treatment plan.

  2. Use critical thinking to determine the best course of action resulting from unexpected outcomes and complications.¹¹

  3. Recognition of when referral to a specialist is in the patient’s best interest (Addenda A and B).

• 1.4 Incorporate animal welfare, client expectations, and economic considerations into the diagnostic or treatment plan:

  1. Evaluation of the patient as a whole, including consideration of dental, oral, and maxillofacial disease as part of general health and quality of life for the patient.

  2. Present a range of options to the client, addressing all health needs and dental, oral, and maxillofacial disease in the context of overall wellness. In cases of established periodontal disease, educate owner that professional intervention is necessary and the patient requires more than prophylaxis care or home care but periodontal therapy and/or oral surgery is indicated.

• 1.5 Prioritize situational urgency and allocate resources:

  1. Triage cases to address the most urgent problems.

  2. Recognize emergency situations and take appropriate direct action.

  3. Stabilize patients with traumatic dentoalveolar injuries with careful attention to neurological, cardiovascular, and respiratory compromise and other life-threatening injuries.

• 1.6 Adapt knowledge to varied scenarios and contexts:

  1. Extrapolate knowledge to novel species or situations where published data is not available.

  2. Adjust existing protocols or procedures to provide the best outcome for the patient.

• 1.7 Recognize limitations of knowledge, skill, and resources, and recommend consults as needed:

  1. Identify situations in which referral is warranted.

  2. Consider consultation with a board-certified specialist in veterinary dentistry.

Domain 2: Individual Animal Care and Management

• 2.1 Perform veterinary procedures and postprocedure care:

  1. Perform an oral examination with periodontal probing and dental charting based on Triadan tooth numbering (Addendum B—steps in a comprehensive oral examination).

  2. Perform routine therapeutic procedures: professional supragingival and subgingival scaling, polishing, and irrigation. Deliver effective regional anesthesia with appropriate comprehensive pain management through premedication and postoperative consideration. Perform closed root planing, closed and open surgical extraction techniques for each tooth type, and oral biopsy techniques (Addenda F and G).

  3. Perform emergency procedures (eg, ability to ligate palatal or lingual artery for an erosive lesion or laceration when severe bleeding is difficult to control) and be able to place a temporary muzzle to stabilize an acute fracture.

  4. Manage patient comfort. Provide analgesia and postoperative care (Addendum C) analgesia and local nerve block resources.

  5. Provide balanced anesthesia and safe recovery from anesthesia (Addendum C).

• 2.2 Promote comprehensive wellness and preventative care:

  1. Recommend disease prevention measures including avoidance of hard chews, chewing on crates/cages, and other abrading behavior.

  2. Provide dental home care counseling appropriate to life stage, health status, and the patient’s temperament. Provide client education regarding dental diets and treats, dentifrices, rinses, and additives, including information on the Veterinary Oral Health Council Seal of Acceptance for plaque and calculus control.

  3. Advise clients regarding treating the present periodontal and other oral and maxillofacial pathology while working to achieve a healthy periodontium with the goal of moving into a maintenance phase, and encourage clients to establish habits of routine preventative dental care including annual professional dental evaluation and prophylaxis under general anesthesia.

Addenda

1. History Questionnaire

   1. Obtain dental-specific history as it relates to dental and oral-maxillofacial health (questionnaire attached below as Addendum K).

   2. Assess animal’s temperament and safe handling for a conscious oral examination.¹⁷

2. Conscious Dental, Oral, and Maxillofacial Examination

   1. Facial conformation and symmetry of head and neck including palpation of lymph nodes, salivary gland, and intermandibular space.

      1. Examination of lymph nodes and salivary glands, including assessment of size, shape, firmness, and movability of lymph nodes and salivary glands.

   2. Evaluate gingiva (attached and unattached).

      • Normal gingiva.

      • Gingivitis.

      • Gingival enlargement or gingival masses.

      • Gingival recession.

   3. Distinguish the differences between plaque and calculus and its role in periodontal disease. Be able to explain the origin of and maturation of dental plaque and progression to inflammation (gingivitis) and pathophysiology of bone loss (soft and hard tissue attachment loss). Identify calculus and its role in development of periodontal disease and not its cause.

   4. Examination of teeth.

      1. Knowledge of canine dentition and classes of occlusion.

         • Know deciduous dentition morphology and anatomy.

         • Know permanent adult dentition morphology and anatomy.

      2. Knowledge of feline dentition.

         • Know deciduous dentition morphology and anatomy.

         • Know permanent adult dentition morphology and anatomy.

      3. Knowledge of eruption dates of deciduous and permanent adult teeth in dogs and cats.

      4. Recognition of missing teeth, supernumerary teeth and roots, developmental structural tooth defects like enamel defects, dilacerated roots, and bi- or trigeminy formation.

      5. Fractured teeth. Recognize the following:

         • Enamel fracture.

         • Uncomplicated crown fracture.

         • Complicated crown fracture.

         • Uncomplicated crown/root fracture.

         • Complicated crown/root fracture.

         • Root fracture.

      6. Recognition of discolored teeth and sequalae of endodontic disease.

      7. Resorptive lesions

         • Ability to recognize visible resorptive lesions.

      8. Examination of the hard and soft palate giving attention to rugae and incisive papilla, palatoglossal folds, and tonsils.

      9. Examination of the tongue and taste buds and investigation for foreign bodies.

3. Administer Balanced Anesthesia for Dental, Oral, and Maxillofacial Examination

   1. Demonstrate competency related to anesthesia of the dental patient (in concert with day one skills required by the anesthesiology college).

      1. Preanesthetic medications.

         • Analgesics (understand classes, pathways, outcome).

         • Anticholinergics (when to use, why to use).

      2. Knowledge of gas anesthetics available and proper administration of general anesthesia.

   2. Monitor anesthesia (in concert with day one skills required by the anesthesiology college).

      1. Proficiency in understanding the following:

         • EKG.

         • End-tidal CO₂.

         • Blood glucose.

         • Blood pressure.

         • Heart rate.

         • Respiration rate.

         • Core temperature.

   3. Comprehend the value and appropriate use of regional analgesia:

      • Understand benefits of regional analgesics.

      • Understand dosage, mechanism of action, and duration of regional blocks.

   4. Be able to safely perform regional nerve blocks (regional analgesics) in the dog and cat.

      • Infraorbital block.

      • Extended infraorbital block.

      • Maxillary block.

      • Mandibular block.

      • Intraoral.

      • Extraoral.

      • ± mental block.

      • Knowledge of complications of nerve blocks.

   5. Postoperative care of patient.

      • Immediate postoperative recovery of patient (see anesthesiology requirements).

      • Analgesics.

      • Anti-inflammatory medications.

      • Consideration of the indications for antibiotic administration.

4. Dental, Oral, and Maxillofacial Examination Under General Anesthesia

   1. Repeat the steps listed in Addendum B (Conscious Dental, Oral, and Maxillofacial Examination), with patient nonmobile and with attention to detail and adequate illumination and magnification. Pay careful attention to any observed foreign material in interdental spaces, in palatal rugae, or sublingual tissue. Palpate the hard palate and tongue to detect any foreign bodies or trauma (ballistic or otherwise). Evaluate normal range of motion for temporal mandibular joint.

   2. Proficiency in the use of a periodontal probe and dental explorer; knowledge of normal sulcular periodontal probing depths in dogs and cats (0 to 3 mm and 0.5 to 1 mm); and understanding of attachment loss versus periodontal pocket depth, attachment loss at furcal areas, detection and grading of mobility, identification of caries, resorption, pulp exposure, and dental fractures. Proficiency in visual inspection and probing for suppuration and fistulas and exploration of draining tracts.

   3. Competence in dental charting (Supplementary Table S1).

      1. Furcation exposure assessment (AVDC Stages 1, 2, and 3).

      2. Ability to identify, chart, and understand clinical significance and treatment options for malocclusions including AVDC Class 0, I, II, III, IV; crowding; rotation; developmental abnormalities including enamel defects like hypocalcification, bigeminy, and trigeminy; palatal defects or hypoplasia; craniomandibular osteopathy; and dental disease including canine and equine caries, tooth resorption, discolored teeth, and oral and dental tumors including gingival enlargements and neoplasia.

      3. Understand the pathophysiology of endodontic inflammation (pulpitis), nonvitality, and tooth discoloration. Be able to use imaging to evaluate for lesions of endodontic origin (LEO signs), including lack of lamina dura, widened pulp canal (arrested development), decreased periapical bone density, sclerosing osteitis, narrowed pulp canal, periodontal space widening, and internal and/or external root resorption.

5. Proficiency in Performing Intraoral Dental Radiography and Knowledge of Different Imaging Modalities

   1. Ability to position radiographic equipment to obtain full-mouth images including 3 mm around the apices of all teeth.

   2. Interpret radiographs as they relate to normal dental anatomy, tooth maturation as it relates to dentin and canal widths, deciduous (primary) versus adult (secondary) dentition anatomy, and periodontal disease (bone loss/bone height). Compare images to known resources to identify the stage of periodontal disease (AVDC Stage 1 through 4).

   3. Establish a diagnostic treatment plan based on clinical presentation and, if needed, radiology interpretation from a specialist.

   4. Establish a treatment plan and complete a clinical presentation to the client to communicate the stage of periodontal disease, the etiology, and the treatment and preventative strategies to maintain good oral health.

   5. Knowledge of different imaging modalities and the advantages and limitations of each, including conventional CT, cone beam CT, and MRI.

6. Perform Supragingival and Subgingival Scaling, Polishing, and Irrigation

   1. Know when to recommend more advanced periodontal procedures, including closed and open root planning. Learn to perform closed root planing. Consider referral for advanced periodontal surgery, including gingival grafts, bone grafts, and augmentation, to support dentition when indicated and requested by the owner.

   2. Familiarity with ultrasonic scaler types (piezoelectric and magnetostrictive) and their proper use.

   3. Experience with hand curettes and proper adaption to remove subgingival calculus and prevent iatrogenic trauma to hard and soft tissues of the oral cavity.

7. Knowledge of Indications for Exodontia (Extraction of Teeth)

   1. Understand instruments to perform oral surgery:

      • Luxators.

      • Elevators.

      • Periosteal elevators.

      • High-speed handpieces.

      • Dental burs, including types used for specific purposes.

      • Surgical blades and handles, including types and design for specific incisions.

      • Sutures appropriate for oral surgery.

   2. Perform closed tooth extraction.

   3. Perform open surgical extraction of the following:

      • Maxillary canine tooth (104,204) in the dog and cat.

      • Maxillary fourth premolar (108,208) in the dog and cat.

      • Two rooted teeth and the mandibular molar (409,309) in the cat.

   4. Indications for crown amputation in the cat and dog.

      • Crown amputation in a canine, premolar or molar teeth in the cat.

   5. Basic approaches to tooth root tip retrieval.

   6. Prevention of mandible/maxillary trauma and other complications during tooth extraction.

   7. Develop a treatment plan, consider complications, and prepare for successful outcomes.

8. Oral Medicine

   1. Identify the patterns of oral inflammation, including pericoronitis, caudal mucosal, palatoglossal, esophagitis, cheilitis, glossitis, palatitis, contact, and generalized. Consider differential diagnosis of feline gingivostomatitis,¹⁹ ulcerative stomatitis, pyogenic granulomas, eosinophilic disease, viral, traumatic, caustic exposure, benign, and malignant neoplasia.

   2. Describe clinically significant features of common maxillofacial conditions, including masticatory muscle myositis, neurological disease, contact mucositis, and temporal mandibular joint disorders.

9. Oncology

   1. Recognition of oral neoplasia.

   2. Indications for biopsy (incisional vs excisional).

   3. How to perform a diagnostic oral biopsy.

10. Beneficial Exposure to Supplement the Core Competencies

    1. Endodontics.

       1. Awareness of endodontic pathology.

       2. Treatment options including root canal therapy and vital pulp therapy.

    2. Restorative and prosthodontics.

       1. Exploration of restoration techniques and materials.

    3. Surgical oncology.

       1. Knowledge of types and embryonic origins of odontogenic tumors.

       2. Knowledge of most common oral tumors in dogs and cats.

       3. Define positive and negative attributes of different imaging modalities for evaluation of oral tumors.

       4. Exposure to surgical oncology, radiation oncology, and medical oncology on a referral basis.

    4. Maxillofacial trauma.

       1. Exposure to clinical cases and outcomes.

       2. Knowledge of fundamentals of maxillofacial fracture/bone repair.

       3. Knowledge of importance of proper occlusion in fracture fixation and outcomes.

11. Patient Dental-Specific History Questionnaire

    1. What is the reason for the visit?

    2. When did you first notice the problem?

    3. If applicable, how did this occur?

    4. Have you observed any abnormal behaviors (eg, pawing at the face, decreased appetite, showing any signs of pain when touched near the mouth, drooling, sneezing, nasal discharge)?

    5. When was your pet’s last visit to the veterinarian?

    6. Who should we contact for the most recent medical history? Is there recent bloodwork or labs?

    7. How long have you had your pet?

    8. Are you providing oral hygiene care at home for your pet (eg, brushing, rinsing, gels, water additives, wipes, dental diets, chews, or treats)?

    9. What was the date and location of the last dental cleaning under anesthesia?

    10. What food is your pet currently eating? Is it wet food or dry food? Any dietary restrictions?

    11. Have there been any changes in eating, drinking, or chewing?

    12. What treats and/or chew toys are given to your pet?

    13. List all medications and/or supplements that your pet is currently taking: name of medication, dose, concentration, frequency, prescription date (or, if this is a long-term medication, when it was first prescribed), and prescriber information (clinic and doctor name).

    14. Is your pet current on flea and tick prevention and heartworm prevention?

    15. Is your pet current on recommended vaccinations (including, for dogs, current status of canine adenovirus type 1, canine adenovirus type 2, distemper, parainfluenza, and parvovirus vaccination and, for cats, feline panleukopenia, felines herpesvirus-1, calicivirus, and FeLV vaccination and retroviral status)?

    16. Is your pet current with the rabies vaccine? When was the last rabies vaccine?

    17. Does your pet have any medical conditions (eg, heart conditions, diabetes, renal or hepatic disease, seizures, arthritis, allergies, eye conditions, or major surgeries)?

    18. Has your pet had any reactions to previous anesthesia and/or medications?

    19. Do you have any other questions or concerns that you would like to discuss with the doctor during your appointment?

Discussion

The AVMA COE now recognizes that dentistry deserves a place in the curriculum based on the documented high frequency of dental conditions, particularly periodontal disease, in companion animals. An additional cause for inclusion of dentistry in the curriculum is the documented association of increasing severity of periodontal disease with increasing severity of changes in distant organs (kidney, liver, heart) and circulating acute-phase proteins.¹⁸

This article provides specific recommendations for what should be included as content in all veterinary school curriculums.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose. No third-party funding or support was received in connection with this paper or the writing or publication of the manuscript.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org