The Complete Dental Examination

THE COMPLETE DENTAL EXAMINATION
Unless you want to wait until you experience discomfort, a checkup is the best preventive strategy. It is important that the dentist perform a thorough examination. In my office, I divide the exam into 10 segments:

1. Medical History
2. Dental History
3. Chief Complaint
4. Facial and Soft Tissue Exam
5. Tooth Mobility
6. Carious Lesions (cavities) and Existing Restorative and Prosthetic Status
7. Periodontal Screening
8. Occlusion and Diagnostic Study Models
9. Temporomandibular Joints
10. Radiographs

When I have completed this examination, the patient is scheduled for a consultation. Before the consultation appointment, I review all the information12 and prepare a treatment plan or treatment options, depending on the complexity of the case.
Let’s review the significance of each part of the examination.

The Medical History

I have found very few medical conditions that preclude providing quality dental care and obtaining good results. Generally, very sick, aged, or disabled patients do not appear at a dental office because they are either bedridden and/or hospitalized, or they receive dental care at special facilities. Patients who come to my office complete a health questionnaire. I evaluate responses to see if health issues affect dental status or treatment needs. The complete medical history helps avoid unforeseen treatment complications. For instance, diabetic patients may be more prone to infections and heal more slowly. I must determine the severity of their disease and the medications they are taking. In treating most diabetic patients, I have not seen the dramatic detrimental conditions and treatment results textbooks suggested would occur. A history of liver dysfunction, may be significant in terms of a bleeding or healing problem in surgical procedures.
Allergies are significant, particularly, for instance, if my patient indicates an allergy to Penicillin. If my first choice for an antibiotic were Penicillin, I would administer Erythromycin instead. It is important to know what medications patients are currently taking in order to avoid interactions with drugs I may prescribe.
Occasionally, the dentist will discover undiagnosed medical conditions that show clinical signs of pathology in the oral cavity: i.e., cancer, AIDS, certain vitamin deficiencies, or numerous other conditions. If any of these conditions are apparent, the dentist should refer the patient to the appropriate physician.

Dental History

In taking a full account of patients’ dental history, I look not only at the existing dental work, but at their past experience and how this will affect future care. If I see sloppy or substandard restorations (when they exist, they are usually obvious to a dentist), I wonder whether the patient is aware of the condition. I believe it’s important to discuss this with them, look for reasons why this has occurred, and show them how quality care differs from their previous treatment. When their visit to my office is emergency based, patients are usually in pain. Then my primary objective is to deal only with their emergency needs in a gentle and compassionate manner. Once this is accomplished, I re-schedule them for a complete examination.
Fear of the dentist and financial constraints are two of the most common reasons for dental neglect. In order to provide proper therapy, the dentist must “discover” and deal with these factors individually.

Chief Complaint

Why did the patient come to my office? Though there may be many treatment requirements, prioritizing them is important. If a patient requests that I fix or do just “this one thing,” it’s up to me to evaluate the request as it relates to what may be best. For instance, if a patient’s main concern is a chipped tooth, yet my examination reveals other areas of deterioration such as a deep cavity that left untreated will cause pain and require root canal therapy, I try to accommodate the original request while also educating the patient.

Facial and Soft Tissue Exam

In this part of the examination, I look for anything abnormal—a swelling, facial lesions, and so on—that may require treatment or referral to a specialist. Early detection of cancer can save a patient’s life. Undiagnosed medical conditions are sometimes first observed during this part of the examination.

Tooth Mobility

Normally, teeth are not mobile. When I detect mobility, I immediately evaluate the biting relationship of the teeth. Is there traumatic occlusion? Have the teeth shifted due to loss of a tooth? Does the patient have periodontal disease with accompanying bone loss? Evaluation of the x-rays (radiographs) will help diagnose the problem.

Carious Lesions (Cavities) and Existing Restorative and Prosthetic Status

I use an explorer (a metal, pointed probe) to gently investigate the pits and fissures of the teeth to detect cavities. I check to see if present fillings (restorations) are sound with no recurrent decay or voids. I also evaluate bridges and other prosthetic appliances: Do they have proper anatomy? Is the fixed (cemented) bridge functioning properly? Can the patient perform required oral hygiene procedures under the bridge? Are the removable partial dentures irritating the soft tissues? Are the clasps designed properly, or are they traumatizing the teeth they contact?
If the patient has no natural teeth (totally edentulous) and is wearing complete upper and lower dentures, how are these functioning? Bone and soft tissues tend to change over time, causing the dentures to shift from their original proper relationship. The bite may become traumatic, and tissues may become red and irritated. Preventive therapy may include everything from using soft relining materials to remaking the defective dentures. Ultimately, avoiding timely treatment in dealing with these problems exacerbates the condition. Neglect results in more complicated and expensive therapy with a diminished prognosis.
And what about dental implants? These restorative devices need periodic maintenance—for life! This is one of the major disadvantages of any complex dental treatment. Keeping your own natural teeth healthy and avoiding any prosthetic replacement makes the most sense in relation to the time and expense of maintenance requirements.

Periodontal Screening

Screening involves a general appraisal as compared to a more complete and thorough examination. I evaluate the color, texture, and bleeding tendencies of the tissues adjacent to the teeth, noting the amount of plaque and tartar buildup. I use a measuring probe to detect periodontal pockets (pathologic separation between the gums and the teeth). The radiographic examination will reveal bone destruction, tartar beneath the gum line, and other pertinent information. If the periodontal status indicates a clinical deterioration, the patient will be scheduled for a more thorough periodontal examination where specific measurements and charting of pocket depths will be recorded.

Occlusion and Diagnostic Study Models

Occlusion is the bite—the relationship between the upper and lower teeth. Though the teeth should occlude in a certain manner, deviations almost always exist; there is no absolutely normal biting relationship. When trauma is present with either tooth mobility or other clinically related factors, corrective treatment is indicated. When necessary, impressions are taken of the upper and lower teeth, poured in stone to make diagnostic casts, and mounted on a device that simulates the relationship of the jaws (an articulator). This makes it easier to evaluate the bite and demonstrate this information to the patient.

Temporomandibular Joint

The temporomandibular joint (TMJ) is the ball-and-socket relationship that connects the movable lower jaw (the mandible) to the upper skull. Abnormalities in this joint may result in chronic symptoms such as headaches, clicking sounds, or muscle pain. The “inexact” nature of this problem has resulted in a cottage industry of TMJ therapists—some legitimate, others not. My exam evaluates the general status of this anatomic area. Rarely have I discovered subjective or clinical pathology.

Radiographs

A routine radiographic examination (peri-apical x-rays) usually involves about 16 radiographs, called a full series. Evaluation will generally show if cavities are present, the status of wisdom teeth (third molars), signs of periodontal disease or other areas of pathology. When a wider view is necessary, the dentist will request a panoramic radiograph.13 Dental x-rays are very safe. Newer films requiring little radiation, along with the use of a lead apron, protect the patient. Moreover, digital radiography is rapidly replacing standard x-ray film. It requires even less radiation, and with computer enhancement, affords better diagnostic capabilities.