Oral Examination 

Examination Process

Oral diagnosis is seldom just the identification of a single disease in the mouth, but rather it is a disclosure of conditions of an oral or a systemic nature that will require treatment or management. The dentist should be concerned about the patient's total health, the relation of the oral cavity to the patient's general systemic health, the effect of systemic health on the management of the patient's oral conditions, and the patient's self image. A diagnosis need not be negative. It can be a confirmation of good oral health, healthy tissues, and the absence of disease. Modern dentistry places emphasis not only on the control of disease, but also on the prevention of disease.

To collect data about a patient is an ongoing process. Typically a patient visits the dental office as a new patient who seeks complete and thorough treatment for conditions that he or she may or may not be aware exist, as an emergency patient for treatment of a specific or chief complaint, or as a returning patient of record for continuing care. Each of these situations requires some type of clinical and radiographic examination, a review of the medical history, and a diagnosis. Regardless of the course of treatment the patient may need, the most complete and accurate information must be obtained to enable the dentist to obtain an accurate diagnosis.

The phases of oral diagnosis focus on the patient's personal, medical, and dental history: the clinical examination; radiographic; photographic, and diagnostic models; laboratory tests; and the diagnosis. A diagnosis is seldom made after the review of a single phase of history. Each phase provides the dentist with different but interrelated information, and when all are combined they contribute to the final diagnosis.

Classification of Dental Instruments

Another of G.V. Black's major contributions to operative dentistry was the classification of dental instruments. He classified instruments into six categories according to their function or use: cutting (hand and rotary); condensing; plastic; finishing and polishing (hand and rotary); isolation; and miscellaneous. Since many changes have taken place in the twentieth century, the list below is a modification of these classifications representative of hand instruments commonly used in operative dentistry today. Technology moves at such a rapid pace that it is possible new categories can soon be added to this list. This classification should enable the assistant to review instruments according to their function and then identify them according to their physical characteristics.

Table 1 provides a descriptive overview of each of the instruments in each of these six categories. For any dental assistant the task of learning all of the dental instruments in the office seems overwhelming at first; however, this table, combined with a review of manufacturer catalogs and actual visualization of instruments in action will make this task easier.

We have added the category of examination instruments to designate instruments used specifically for examining the teeth and oral tissues. Examination instruments may be used to examine the tooth or other structures during an initial oral diagnosis or after placing a restoration.

The explorer, mirror, and cotton pliers are three instruments that are basic to every dental procedure. These instruments are generally the first three instruments in sequence on most preset trays. The explorer and mirror are frequently used simultaneously during the examination of a tooth. Other examination instruments include the periodontal probe, an Expro, and articulating paper forceps.

Table 1: Classification of Hand Instruments

Examination Instruments

Explorer 

Articulating paper forceps
Mirror  Probes
Cotton pliers  

Cutting Instruments

Angle former 

Gingival marginal trimmer
Chisel  Hatchet
Excavator  Hoe
Insertion/Condensing Instruments

Plastic instrument 

Condenser
Placement instrument Gingival cord packer
Amalgam carrier  

Carving Instruments

Anatomic  Smooth surface
Finishing and Polishing

Burnishers 

Amalgam files
Orangewood stick Knives
Finishing strips  
Adjunct
Thumb forceps  Pliers
Scissors  Spatulas
Dappen dishes Matrices
Napkin chains  


Explorer

An explorer is used to detect irregularities in the tooth or restorative surface, detect calculus or other anomalies during a scaling procedure, and aid in detecting carious lesions in the tooth surface. This instrument is most commonly a DE instrument, but it is also supplied as an SE instrument. The working ends of this instrument may be tapered, right angled, shaped like a shepherd's hook or a cow's horn, or may be any combination of these various shapes. The variations in shape aid the operator in gaining access to the various areas of the mouth. Each operator will have favorite explorers for various procedures, and the dental assistant should become familiar with the application of the various explorers that operator may use. Fig. 1 illustrates several varieties of explorers. It is common today to find explorers with tip ends that are made of graphite for use with resin materials. The use of graphite eliminates marring or discoloring the restoration.

Mirror

The mouth mirror is used to provide indirect vision; to provide indirect illumination to improve vision in the posterior of the mouth; and to retract the cheek, lip, tongue (Fig. 2). Dental mirrors come in a variety of sizes ranging from 5/8 inch to 2 inches (Fig. 3).

Mirrors are provided in disposable styles, single or double sided, and are either flat surface, concave (providing magnification), or front surface, which has a reflecting surface on the front of the lens rather than on the back to eliminate ghostlike images. Nondisposable mirrors come with attached or cone socket handles.

Tissue/Cotton Pliers or Forceps

Tissue forceps or cotton pliers are used to hold onto materials when transporting them from one place to another. Three types of pliers common to operative dentistry include the cotton or dressing pliers, articulating paper forceps, and thumb forceps (Fig. 4). The first two forceps are used intraorally, whereas the thumb forceps is used extraorally.

The standard cotton pliers or dressing pliers are used to transport materials into and out of the oral cavity. These instruments are used frequently during a cavity preparation to dry the cavity with cotton pellets, to transport medication on a cotton pellet to the preparation, or to carry other materials to the site. These pliers are supplied with serrated or smooth beaks, with or without a groove in the beak, and with plain or locking handles. The tips may be monangled or binangled. 

Click here to view Figures 1 - 4.

Charting Oral Conditions

The charting of oral conditions is a form of dental shorthand. A variety of symbols (Table 2) and abbreviations (Table 3) are used to indicate specific conditions that exist on the teeth and on the supporting structures of the mouth. The use of symbols makes it easy to look at a dental chart and to identify easily conditions that exist in the mouth, without reading a detailed narrative.

Table 3 lists symbols that are commonly used for variety of conditions that exist in a patient's mouth. In some areas alternative suggestions have been made, since there are many options. This table represents commonly used symbols; however, each dental specialty area may have symbols that are unique to the specialty. Some dentists may use symbols that work effectively for them while other dentists may prefer the use of color (e.g., yellow for gold, blue for amalgam, red for composite) to denote different types of restorations. No particular system is right or wrong; however, charting symbols need to be identified and used consistently by all members of the staff within the office. 

Click here to view Table 2.

Table 3: Suggested Charting Abbreviations

Abbreviation Term Abbreviation  Term

@

at

FH

Family history

a, am, ag

Amalgam

FLD

Full lower denture

amp

Ampule

FMS

Full mouth series

amt

Amount

FMX

Full mouth x-ray

anes

Anesthesia

FR or Frac

Fracture

appl

Applicable, application, appliance

frag

frec

Fragment

Frequent, frequency

approx

Approximate

FUD

Full upper denture

BF

Bone fragment

G

Gold

BP

Blood pressure

GF

Gold foil

Br

Bridge

Gl

Gold inlay

BW

Bite-wing radiograph 

ging

Gingiva, gingivectomy

Bx

Biopsy

HBP

High blood pressure

C

Composite

Hx

History

carbo

Carbocaine

I & D

Incision and drainage

caps

Capsules

IA

Incurred accidentally

cav

Cavity

IH

Infectious hepatitis

CC

Chief complaint

IM

Intramuscular

CM

Cast metal

imp

Impression

cond

Condition

IMP

Impacted

CSX

Complete series x-rays 

inj

Injection, injury

cur

Curettage

inop

Inoperable, inoperative

CV

Cardiovascular

IV

Intravenous

CVA

Cerebrovascular accident

lab

Laboratory

D or DV

Devital

lac

Laceration

dbl

Double

lat

Lateral

DEF

Defective

ling

Lingual

Dg or Dx

Diagnosis

liq

Liquid

DM

Diagnostic models

LLQ

Lower left quadrant

DMF

Decayed, missing, and filled

LN

Lymph node

DO

Distoocclusal

LRQ

Lower right quadrant

DOB

Date of birth

M, mes

Mesial

DR.

Doctor

mand

Mandibular

EMT

Emergency medical treatment

max

MDR

Maximum, maxillary

Minimum daily requirement

est

Estimate, estimation

med

Medicine, medial

evac

Evacuate, evacuation

mg, mgm

Milligram

eval

Evaluate, evaluation

MO

Mesioocclusal

ext

Extract, external
Fasting blood sugar

MOD

Mesioocclusodistal
FBS Fasting blood sugar mo Month
MS

Multiple sclerosis

TAT

Tablet

narc

Narcotic

TB

Tetanus antitoxin

nc

No change, no charge

TBI

Tuberculosis

NCP

Not clinically present

temp

Toothbrush instructions

neg

Negative

TLC

Temperature

norm

Normal

TPR

Tender loving care

occ, occl

Occlusal

TMJ

Temperature, pulse, respiration

OH

Oral hygiene

Tr.P

Temporomandibular joint

OHI

Oral hygiene instructions

URI

Treatment plan

opp

Opposite

ULQ

Upper respiratory infection

p

Pulse

URQ

Upper left quadrant

PA

Periapical

VD

Upper right quadrant

path

Pathology

wh

Venereal disease

Ped

Pediatrics

wnd

White

PO, postop

Postoperative

x

Wound

preop

Preoperative

xyl, xylo

Times, such as 4x = 4 times; x-ray

prep

Preparation, prepare for treatment

YOB

YR

Xylocaine

Year of birth

prog

Prognosis

- -

Px, Pro, Proph

Prophylaxis

- -

R

Respiration

- -

Rx, RX

Take (thou) recipe

- -

RC

Root canal

- -

req

Requisition

- -

resp

Respiration

- -

RHD

Rheumatic heart disease

- -

ROA

Received on account

- -

SBE

Subacute bacterial endocarditis

- -

sig

Write on label

- -

sol

Solution

- -

stat

Immediately - -

stim

Stimulate, stimulator - -

surg

Surgery, surgeon - -

SX

Symptom - -

T

Temperature - -
tab

-

- -

Extraoral Examination

The extraoral examination observes for asymmetry, lesions, swellings, or discoloration. Data collection begins at this point. It is an important task that requires good listening skills, attention to detail, and a high degree of accuracy. Portions of this examination may be performed by the dental assistant in some states. Regardless of who collects the data, the collection and record must be thorough and accurate.

Data that are collected during this phase of the examination are obtained by observation or palpation. Observation is a visual inspection; it is the act of noting size, shape or contour, and color of tissues. Palpation is to use the sense of touch to denote consistency, whether the tissue is soft, firm, hard, or nodular, and to denote tenderness in tissues when they are palpated.

To palpate external tissues, the operator's fingers will be used on the outer surfaces of the face and neck or one or two fingers may be placed on the inside of the oral cavity, depressing on a finger that is held in an opposing position outside the mouth. Palpation is a gentle but firm tactile pressure.

Conducting an Extraoral Examination

1. Observe facial symmetry (Fig.5-A) Irregularities, such as drooping eyelids or lips, may be associated with some form of weakness in the musculature or other systemic conditions. For instance, prominence of the eyeballs and an enlarge- ment in the neck may indicate that the patient has a severe thyroid condition; a cyst, such as the branchial facial arch cyst, may be causing the asymmetry in the Fig. 5-B.

2. Inspect the skin of the face and neck. Note any lesions, swellings, or discolora- tion (Fig. 5-C). Presence of jaundice, a yellowness of the skin, may be a sign of liver disease or the retention of broken down red blood cells. These condi- tions can contraindicate the use of some drugs. Severe bruises about the head and face area may indicate abuse. The dental professional is required to assume a legal and ethical responsibility for reporting observations of abuse.

3. Inspect the nails. This can be done in comparison with the operator's nails (if those are healthy) to distinguish the difference. Bluish color of a nail bed may indicate a chronic or acute problem with circulation, while pallor may indicate anemia. Rounded clubbing of the fingers may also indicate the presence of systemic diseases. A close observation of the nails may indicate lesions caused by nail biting habits.

4. Observe the hands. The creases in a healthy person's hands retain a normal pigmentation. The vascular bed is close to the surface in the hands and the lack of hemoglobin is evidenced by a lighter color.

5. Examine the lymph nodes. Criteria for this examination include size and shape. Most nodes are approximately the size and shape of a kidney bean; mobility: lymph modes are mobile; single or multiple: most nodes are commonly found singly and even in groups they can be identified as separate entities; when the nodes are multiple or coalesced, it is a sign of a disease process; tenderness is a sign that an inflammatory process has invaded and produced tenderness.

Begin in the submental area, and, with fingers opposing each other, try to trap the lymph node against muscular or connective tissue near the bone or between the fingers (Fig. 5-D). Then proceed to the submandibular: (Fig. 5-E) and the carotid region (Fig. 5-F). When the nodes are examined in the parotid region, the parotid should not be prominent. The preauricular nodes are above the parotid region but are not accessible to palpation. Have the patient turn so that access can be made to examine the nodes in the jugular chain along the sternocleido-mastoides muscle (See Fig 5-G). Run a finger along the side of the muscle to examine these nodes. Examination of the lymphatic system in the head and neck area is important because the vessels of the oral cavity and face drain through these areas, and any evidence of swelling or tenderness in this area may indicate an infection or the presence of a tumor.

6. Examine the TMJ. Place a finger tip anterior to the tragus of each ear and ask the patient to open wide. Any tenderness, popping, clicking, or other abnormal- ity in the opening, such as excessive lateral movement, should be noted. These symptoms may indicate problems with the patient's occlusion or TMJ (Fig. 5-H). 

Click here to view Figure 5.

Intraoral Examination

The intraoral examination is divided into three phases: the soft oral tissues; the periodontium; and the teeth and their occlusal relationship. As with the extraoral examination both visual inspection and palpation are used in this examination. Once again, when intraoral tissues are inspected, the visual emphasis should be on size, shape or contour, and color; palpation should identify the consistency and the tenderness of tissue. Several factors should be considered when intraoral tissues are examined; these are listed below.

At this point in the procedure the patient should be placed into a supine position. The preset tray for this procedure provides the basic instruments for all phases of the intraoral examination.

Armamentarium includes the following (Fig. 6):
Explorer
Mirror
Cotton pliers
Periodontal probe
Articulating paper
2 x 2 Gauze
Napkin/napkin chain
a/w Syringe tip
Articulating paper forceps, optional
Dental floss or tape
Patient's chart or examination sheet
Pencils, lead and colored (optional)

 

Intraoral Tissue Examination
Tissue integrity of covering tissues; the epithelium over the surface should be intact.
Degree of keratinization will vary in different parts of the oral cavity.
Sense of touch will indicate consistency and whether tissue is soft, firm, hard, or nodular.
Sense of touch will indicate tenderness; if a mass is found, if it is mobile or if it is fixed to surrounding tissue.
Bilateral palpation can compare one part to another.
Anatomic consideration; does the anatomy compare or differ to its bilateral counterpart and does it deviate from the normal?

Soft Tissue Examination

The first phase of the intraoral examination begins with examination of soft tissues. The dental mirror may be used to improve vision or for retraction, while the operator performs the following:

  1. Examine the upper and lower lips. Lipstick should be removed if it is worn by the patient. Once the lipstick is removed, the residue of lipstick may still mask color changes or lack of change. Look for a well-defined line of demarcation between the vermilion border and the skin. The folds or lines of the lip should be evident at right angles to the vermilion border. When the lip is palpated it should be supple and the vermilion border should be a distinctive and uniform color that is different from the rest of the labium (Fig. 7-A). Any abnormalities, such as opaque areas on the lip, loss of deep creases, thinning of surface tissue, or loss of line of demarcation between lip and skin, should be noted. Any areas of increased keratinization or scaly patches should be noted. These may be herpetic lesions, small cancers on the lip, or basal cell carcinoma. Until these areas have been diagnosed, the color and character of the lesion should be noted on the patient record (Fig. 7-B).
  2. Inspect the vestibular regions, the frenum, and labial mucosa. Retract the man dibular lip, and expose the mandibular labial mucosa (Fig. 7-C). Redness in this area may indicate a smoking habit. Tiny elevations that indicate the nests of salivary glands will be evident. Similarly, the maxillary lip is raised, and the labial mucosa in this area is examined (Fig. 7-D). In both arches the base of the frenum should be well away from the gingival margin.
  3. At this time the lips should be palpated to determine consistency and presence or absence of firmness, which might be associated with the underlying salivary beds. Any tissue discoloration, lesions, edema, lip or cheek habits, or undue stress on the frenum is noted. Evert and inspect the labial mucosa by palpating the lips between the thumb and forefinger. Any tenderness, swelling, or masses may be an indication of an infection or of small tumors.
  4. Examine the buccal mucosa on both sides of the oral cavity, from the maxillary vestibule to the mandibular vestibule, by retracting the cheek and palpating the tissue. Parotid papilla and nests of labial salivary glands should be evident. Observe the buccal mucosa for the presence of Fordyce spots or linea alba. Identify the characteristics of the tissue and the relationship of the superior and inferior buccal frena to the gingival margins (Fig. 7-E).
  5. Palpate each cheek between the thumb and forefinger to determine the presence of tenderness or of small tumors (Fig. 7-F).
  6. Palpate the parotid salivary glands. Any swelling or tenderness is noted. These symptoms may indicate infection, blockage, or the presence of tumors in these glands (Fig. 7-G).
  7. Progress to the posterior of the arches, using a mouth mirror to examine the maxillary tuberosity and retromolar pad areas. Observe any tissue irritation or tooth eruption in these areas (Fig. 7-H).
  8. Inspect the hard palate, including anterior landmarks, such as the rugae and incisive papillae. Smokers may have increased tissue keratinization in this area. Palpate the entire hard and soft palate with the mid- or forefinger to detect swellings that might indicate an infection in this area or small tumors of the minor salivary glands. When the hard palate is palpated, there should be a continuity of the underlying bone. Tori also may be evident in this region and may go unnoticed unless the region is palpated (Fig. 7-I).
  9. Continue to examine the soft palate posteriorly. When the soft palate is depressed with a finger, an underlying nodular-like area should be apparent. Depress the dorsum of the tongue to increase vision to the soft palate, uvula, and tonsils. By pressing on the tongue with the face of the mirror and asking the patient to say ah, these tissues will be better viewed. Inflammation of the tonsils, if they are present, can be observed, and lesions may be evident on the tip of the uvula, such as a neoplasm or a papilloma (Fig. 7-J).
  10. Examine the dorsum of the tongue. Ask the patient to stick out the tongue. It is grasped with a 2 x 2 gauze. The dorsal surface is inspected, and the tongue is moved laterally to inspect both sides for the presence of lesions (Fig. 7-K). Smokers may have an increase in the length of the filiform papillae and discol- oration of the dorsum of the tongue. Glossitis or geographic tongue may be observed. Ask the patient to raise the tongue to inspect the ventral surface for the presence of tumors (Fig. 7-L).
  11. Examine the floor of the mouth. In the anterior portion of this area the lingual caruncle and sublingual folds are evident on both sides. A mirror can be used for retraction of the tongue to examine the color of the tissue.
  12. Palpate the lingual aspect of the mandible. This is a location where mandibular tori may be evident. Run a finger along side-to-side to trap soft tissues with an intraoral finger and extraoral hand. In this area are the submandibular glands and the sublingual gland, though the latter is not palpable as an isolated mass, (Fig. 7-M).
  13. Check secretions of the salivary glands. Dry off the ductal openings of Wharton's duct, apply pressure under the anterior of the mandible and look with a mirror at the lingual surface under the tongue. Press upward the parotid orifice and dry the site with a 2x2 gauze. With light pressure to the cheek, stroke the area to stimulate saliva flow from the duct.

A typical charting of the soft tissue examination would be recorded on the patient's examination sheet.

Click here to view Figure 7a

Click here to view Figure 7B

Periodontium Examination

This phase of the oral examination includes assessment of the tissues that support the teeth: the gingivae, cementum, periodontal ligament, and the alveolar and supporting bone. The alveolar and supporting bone evaluation requires the use of dental radiographs, while the other tissues are evaluated visually and with the use of a periodontal probe and mirror. The operator will use a variety of terms to describe the conditions of periodontium and accumulations of accretions. The assistant should be familiar with descriptive terms that are used to identify the location, severity, color, shape or form of the periodontium. Table 4 lists key turns that are commonly used to describe these conditions. Additionally, the dental assistant should have an awareness of the clinical characteristics of healthy and unhealthy gingival tissues.

Table 4 provides an overview of the most common clinical characteristics of the gingival tissues. Fig. 8 depicts several shapes and forms of the periodontium. During the periodontal examination the following findings are recorded in the patient's chart:

1. General health of the gingivae and notation of any signs of inflammation

2. Location and amount of plaque and calculus

3. Lack of attached gingiva

4. Presence and depth of periodontal pockets

5. Presence of furcation involvement, where pockets exist in multirooted teeth

6. Mobility of teeth

7. Position of teeth

8. Effect of existing restorations on gingival health

The periodontal probe and mouth mirror are the primary instruments that are used in this phase of the examination. The mouth mirror is used for indirect vision, illumination, and retraction, while the probe aids in determining the presence of periodontal pockets or furcation involvement. Data from this examination are recorded during each of the phases of the examination. 

Table 4: Terms Commonly Used to Describe Conditions of the Periodontium

Term Meaning

Localized

The condition is confined to one area, to one tooth, or to a small segment of teeth

Generalized

Evident throughout most or all of the mouth

Slight

Beginning evidence or early states of the condition

Moderate

Significant amount of progression, but not to the advanced stage

Severe

Most advanced stage

Bulbous

Enlarged, swollen, and rounded

Blunted

Receded, not sharp, rounded

Cratered

Crater-like depression in the center of the papillae

Normal, healthy

Tissues are dense and fibrous; In Caucasians the tissue will be uniformly pale pink; areas of pigmentation, from light to dark brown, may occur in various skin colors or races

Soft, spongy

Tissues are swollen and contain fluid

Stippled

Tissues contain many tiny indentations, a healthy condition

Bleeding

When gently probed, tissues bleed

Recession

Margin of gingiva located apical to the CEJ

Cleft

Narrow slit-like recession that occurs where margin tissue is destroyed
Red This is erythema and indicates early or acute inflammation
Bluish purple This is cyanosis and indicates an inflammation of chronic, well-established nature

Click here to view Figure 8.

Observing Gingival Health

1. Visually observe the buccal gingiva by retracting the cheek with the mirror. Note changes in color, form, and texture throughout the segment.

2. Use the periodontal probe to gently press against the attached gingiva (Fig. 9), the gingival margin, and the interdental papilla to determine the firmness of the tissue.

3. Probe the interdental papilla area to identify the presence of inflammation or bleeding.

4. At sites of gingival recession, measure the depth of the recession from the gingival margin to the CEJ.  

Continue this process around other segments of the mouth. Findings from this phase of the examination would be recorded on the patient's record.


Probing the Periodontium

The periodontal probe measures the depth of the gingival sulcus or periodontal pockets (Fig. 10). Various types of probes are available. The working end of each of these probes is calibrated in millimeters to facilitate in reading depth measurements. Periodontal probes are available with varying millimeter readings: 3, 6, 9, and 12 mm; l, 2, 3, 5, 7, 8, 9, 10 mm; and 3, 6, 8 mm, or the probes are noncalibrated, as in a probe that is specifically designed for examinations of furcations. Probes are also available with alternate colored bands to designate depth. Some operators prefer the color-coded probe for increased visibility.

Measurements are recorded at six points tooth_three from the buccal (distobuccal, buccal, and (mesiobuccal) and three from the lingual surface (distolingual, lingual, and mesiolingual) as shown in Fig. 11. The assistant records these data as the operator probes the periodontium to identify the presence of periodontal pockets. The operator actually walks the probe around the tooth, beginning at the distobuccal area and continuing around to the mesiobuccal area (Fig. 12). The measurements for each area are recorded (Fig. 13) in numeric form or in graphic form. This procedure is continued around the arch on the buccal aspect, and then the operator transfers to the lingual aspect before proceeding to the opposite arch. A heathy periodontium is one that can be probed at 2 to 3 mm. In most cases only measurements that deviate from the normal are recorded.

An alternative to manual periodontal probing is the automated system shown in Fig. 14. This system provides highly accurate and repeatable periodontal
measurements by using a probe with constant pressure. The system requires only a single operator and records, stores, and prints a periodontal examination automatically.

During periodontal probing the operator may encounter bleeding, sensitivity, calculus, or saliva. Therefore the assistant must observe the probing sites regularly and use the HVE tip as needed to remove fluids and debris. Frequently the operator may request that a specific site be dried thoroughly with air to improve visibility or to gain access to the gingival sulcus. 

Click here to view Figures 10 - 12.

Click here to view Figures 13 - 14.

Probing the Furcation

When a periodontal pocket extends apically and severe bone loss occurs in multirooted teeth, often the furcation area becomes involved. Examination of the furcation is necessary to determine the degree of involvement. The straight periodontal probe, a special furcation probe, or even a curet scaler can be used to determine if bone still fills the area between the roots. A furcation is charted as shown in the table of symbols.

Determining Mobility

Bone loss from periodontal disease can create tooth mobility as a result of progressive loss of the periodontal attachment. The operator will determine the degree of mobility by exerting force in a buccal-lingual direction. Each tooth is tested in a systematic method, generally beginning in the maxillary right quadrant, proceeding to maxillary left quadrant, from there to the mandibular and concluding on the mandibular right. Mobility is charted as shown in the table of symbols and may be classified as the following:

 

+ mobility Movement that is barely discernible
I mobility Movement from buccal to lingual totaling 1 mm
II mobility Movement from buccal to lingual totaling 2 mm
III mobility Movement from buccal to lingual totaling 3 mm 

 
Teeth

Much information needs to be recorded about the teeth. The symbols described in the table are especially helpful in this phase of the examination. All existing restorations, missing teeth, malpositioned teeth, dental caries, or other anomalies that exist on the teeth are recorded at this time. The operator may dictate the information, while the assistant records it on an examination sheet. The operator uses the mirror and explorer for this phase of the examination. The explorer aids in probing and examining all surfaces of the teeth. At this point the assistant may change from a lead pencil to a colored pencil if the office uses a color-coding system to denote different restorations. Note these pencils may be packaged and sterilized and should receive the same infection control care at the end of the procedure as other instruments receive.

The operator will typically begin in the maxillary right or left tuberosity area and progress to the tuberosity area on the opposite side of the arch, describing any abnormalities as each tooth is examined. The operator then drops down to the mandibular arch and continues examining around to the opposite side of the mouth. For instance, conditions illustrated in Fig. 15-A, might be described in the following manner:

#1 is missing

#2 has mesioocclusal caries

Food impaction between #3 and #4

Diastema between #8 and #9

#9 has mesial caries

#12 is rotated distally

#13 is missing

#14 is shifted mesially

#15 is partially erupted

#17 needs to be extracted

#18 has a beginning furcation

#19 has furcation involvement

#20 has a defective distoocclusal amalgam

#23 has mesiofacial caries

Between #26 and #27, there is an open contact

#28 is hypersensitive

#31 has cervical buccal caries

#32 is hypererupted

The three charts in Fig. 15, B through D, show examples of oral examinations that were completed for three different patients who had a variety of oral conditions. The codes used in these charting exercises are from Table 3.

Occlusion

The manner in which the maxillary and mandibular teeth contact is referred to as occlusion. The relationship of the two arches as they occlude (close together) is included as part of the oral examination. The operator evaluates how the patient opens, closes, and laterally moves the arches to determine if any abnormalities exist. Factors that affect proper occlusion include the relationship and size of the arches to each other; premature contact; teeth that are rotated, hypererupted, unerupted or crowded; occlusal relationships, including crossbite, overjet or overbite. Such abnormalities can cause damage to the periodontium or the temporomandibular joint, or they can create increased wear patterns on the teeth.

Examining the Occlusion

The operator asks the patient to gently close the arches together, and the patient brings the dental arches together in a normal position: centric position. Often, when a patient is directed to close in centric or normal position, he or she may find it difficult to close in this position or may want to bring the anterior teeth together in an end-to-end relationship. The operator may need to ask the patient to relax and bite on the back teeth. The operator may have observed the patient's occlusion earlier in the examination, so there will be an awareness of the proper occlusion before it is checked.

Articulating paper or marking paper is placed between the arches, and the patient is directed to bite down and slide from side to side. This action marks the surfaces of the teeth that are in improper articulation or gives evidence of interference that could cause occlusal trauma.

Through examination the operator determines whether the patient has normal; Class I; Class II, Division 1 or 2; or Class III occlusion. The clinical examination is combined with photographs, radiographs, and study models to determine the patient's occlusion. Any deviations from normal occlusion may prompt the operator to refer the patient to an orthodontist for further examination and consultation. 

Figure 15A

Figure 15B - Screen Resolution

Figure 15C - Screen Resolution

Figure 15D - Screen Resolution

Radiographic Examination

The radiographic examination is a common reliable diagnostic aid for evaluating the tissues in a patient's mouth, especially those tissues not visible to the naked eye. The intraoral examination is effective in determining anomalies and carious lesions in areas visible to direct examination. The visual and tactile examination used to detect caries is adequate in most areas, but in areas of limited access, particularly the interproximal surfaces of the teeth, the quality of such an examination is restricted by the close contact points of the teeth.

In a radiographic examination, the use of bitewing radiographs aids in diagnosing interproximal caries and determining the level of the bone, the periapical radiograph illustrates the entire tooth and its support tissues, while extraoral radiography provides the dentist a view of the teeth in relationship to other head and neck anatomy.

Interpretation

The interpretation of radiographs for the purpose of diagnosing requires a thorough understanding of radiographic anatomy found on bitewing, periapical, occlusal and extraoral radiographic films. The ability to determine normal from abnormal structures is necessary when radiographs are evaluated. Knowledge of the type, location, size, and radiographic image of each structure is important when normal anatomic landmarks and abnormal structures are viewed and evaluated.

Dental radiographs used in conjunction with the thorough intraoral examination allow the dentist to complete the examination.

Although it is the responsibility of the dentist to diagnose, it is vital for the assistant and hygienist to realize importance of their roles in the radiographic examination. The auxiliaries will be responsible for producing the radiographs. Consequently, a thorough knowledge of proper radiographic techniques, necessary anatomic detail, and proper processing techniques is vital to the success of creating a diagnostically acceptable set of radiographs.

Pediatric Oral Examination

The examination of the oral cavity that is performed for a child is no different from that for an adult. Similar conditions, such as gingivitis, abnormal growths, and carious activity, found in the oral cavity of an adult may be discovered in a child. What may be different is the approach the dentist takes and the clinical examination chart that is used. Examination charts that are commonly used in pediatric dental offices are designed to be able to chart primary and secondary dentition (Fig. 16). Any of the common tooth numbering systems discussed in the oral anatomy chapter are practiced in a pediatric examination. 

Click here to view Figure 16.

Click here to view Figure 17.

Stop and Think

At the end of the procedure

1. Are the appropriate universal barrier techniques observed?

2. Have all the appropriate surfaces been cleaned and disinfected?

3. Has all armamentarium been removed?

4. Has all the equipment been repositioned?

5. Has all the equipment been disinfected or sterilized according to OSHA guidelines?

 

Source: Finkbeiner BL, Johnson CS: Comprehensive Dental Assisting, St. Louis, 1995, Mosby. Reprinted with permission.